Financial- Benedict, Doug (Previous Tenant)

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1 1 rrry • Oregon Department of Transportation ~ RELOCAT(ON FIXED PAYMENT CLAIIVI ~ File No. Name Section Highway - County FAP No. ~. 70 , Proprietor of (~LCC.'s Z3\ located at ~nl~c hereby make application for Fixed Payment in lieu of moving expenses as - a displaced business, ^ farm, p non-profit organization (NPO). I understand that to be eligible for the fixed payment, I cannot be relocated without a substantial loss of existing patronage; and further to be eligible, I must not be a part of a commercial enterprise having more than three other entities which are not being acquired by the State, and which are under the same ownership and engaged in the same or similar business activities. I undertand that the fixed payment is to be based on one-half the "annual net earnings" before Federaf, State, and local income taxes during the two taxable years immediately preceding the tax year of displacement, not less than $1,000 nor more than ~20,000. I understand that the amount of payment 1 receive will be computed from the Oregon Income tax returns filed by myself, copies of which are attached. I understand that the fixed payment is in lieu of all other relocation benefits and that the prerr~ises must be vacated and left clean and orderly. t S~~ ' I certify that I am the proprietor and haye operated the business, farm, or NPO for...4~~-rnonths and that the statements contained herein are true and correct to the best of my knowledge and belief_~ Based on the above, I claim a fixed payment of $ 2c~ ,~~ v - '~ .,e _ ~ `~ -~ ~~.~~f ~ " Appllca~t Oate ApplicaM Oate The subject property was.inspected on and found to be vacant, clean, and orderly. An inspection of the propnetors Oregon Income Tax returns indicates that tFie proprietor should.receive payment. I recommend that the proprie+tor be paid the sum of $ . ~ E. A. . AgenCS Sgnawre ~ - Date Reviewers Signature Oate Form 204 (~ ~~ss) . RELOCATION FIXED PAYMENT APPLICATION . ~ Page 3 of 2 pages