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/ <br />x-- o <br />L ~ <br />I am the dispiaced occu ant of the dwelling at ~D3 p ~~ . My claim is based on <br />a room count of and is in the amount of $ ~ Dd. ~. I elect to move myself and <br />receive an amount based on the number of rooms as established by the Right of Way Agent at the time of <br />negotiations. <br />Number of 1 2 3 4 ~ Plus <br />Rooms <br />Unfurnished $300 $500 $700 $825 $125 for each <br />(Relocatee additional room <br />owns fumiture) <br />Fumished: $275 for the first room plus $40 for each additional room . <br />(Relocatee does not own furniture) - <br />Exceptions: <br />1. Person whose residential move is performed by the agency receives $50. <br />2. Move of a mobife home from the displacement site, actual cost. A reasonable amount may be <br />added for packing and securing personal property for the move at the agency's discretion. <br />3. Occupant of a dormitory receives $50. <br />4. Non-occupants of the dwelling, such as landlords, are not eligible for the schedule move. <br />I understand that, prior to this moving payment being made by the Oregon Department of Transportation, <br />this dwelling must be inspected by a Right of Way Agent and found to be vacant, clean and orderly. <br />I also understand that this schedule move agreement is an alternative to a payment for actual moving <br />costs and related expenses and that I will not be elipible for pay Pnt of addi±iona! c~ovizg c;a~r~s ~r utility <br />~econneciion costs. I vacated the premises on fj r; ~~ 3 O~(~ <br />.z~~ ~~y~ <br />Room Count of certified by: <br />Inspection of the subject property was made on y~' <br />recommend that the schedule move payffjent of $_ <br />....._....... ..y,.a.~. ~ <br />found to b cant, clean, and orderly. I <br />~released. ~ <br />~ <br /> <br />Comments to support approval: <br />$ E. A. ti <br />`_'`~ lP 4 <br />Reviewers Signature Date <br />Form 121 (1/97) <br />Oregon Department of Transportation <br />RELOCATION <br />SCHEDULE MOVE CLAInn <br />