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• <br />Oregon Department of Transportation <br />~ <br />RELOCATION <br />FIXED PAYMENT CLAIM <br />Pay To: <br />• <br />Mailing Address <br />` ~. <br />. L el C7 (l. ~? ~7 ~ <br />- " n ae. ~~~ ~ g~~ J~~ ~.~u~. <br />ClaimanPs Name <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP No. <br />I, ^~o ~x,.~d.~~~- , Proprietor of C~vC.c.. ~ Z3\ located at <br />,nl hereby make application for Fixed Payment in lieu of moving expenses as <br />a displaced business, Q farm, ^ non-profit organization (NPO). <br />I understand that to be eligible for the fixed payment, 1 cannot be relocated without a substantial loss of <br />existing patronage; and further to be eligible, I must not be a part of a commercial enterprise having more <br />than three other entities which are not being acquired by the State, and which are under the same <br />ownership and engaged in the same or similar business activities. <br />I undertand that the fixed payment is to be based on one-half the "annual net earnings" befo~e Federal, <br />State, and focal income taxes during the two taxable years immediately preceding the tax year of <br />displacement, not less than $1,000 nor more than $20,000. <br />1 understand that the amount of payment I receive will be computed from the Oregon Income tax returns <br />filed by myself, copies of which are attached. <br />I understand that the fixed payment is in lieu of all other relocation benefits and that the premises must be <br />vacated and left clean arrd orderly. <br />~ S~~ <br />I certify that I am the proprietor and have operated the business, farm, or NPO for.~rnonths and that <br />the statements contained herein are tn~e and correct to the best of my knowledge and belief. Based on <br />the above, I claim a fixed payment of $ Z.c~ o~v <br />'1j „C _ ~ '-~. a~C" ~~3~~7 <br />AppllcaM Oate <br />ApplicaM <br />o~~ <br />The subject property was inspected on ~-t Zs~ ti and found to be vacant, clean, and orderly. An <br />inspection of the proprietor's Oregon Income Tax returns indicates that the pr prietor hould receive <br />payment. I recommend that the prop~ietor be paid the sum of $ ~s a oo~,~ ~rJ. 31"~-S\S~~ <br /> A <br />E <br />~ . . <br />. <br />~ ~ ~i Z~1 <br />ngenrs Synawre Oate <br />Reviewe~s Signature Oate <br />Form 204 (11/95) <br />RELOCATION <br />FIXED PAYMENT APPLICATION <br />Page 3 of 2 pages <br />