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~ ~ <br />Oregon Department of Transportation RELOCATION <br />RESIDENTIAL OCCUPANT INTERVIEW <br />^OWNER [~jTENANT <br />Property Address ~ , <br />~ ~ ~~u~,~-'~ ~~ # / <br />Date of Occupancy ~'/ ~ Contract Rent ~ ? <br />Attach copy of rental agreement or rent receipt <br />Estimated Monthly Utility Costs: <br />E[ectricity ~ Heat ~- <br />Water ~ Sewer -- <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP No. <br />::> :: :;. .....:..:..:................:....;:.::...;: :,:..:.::.......::..;..;......:..:.;:.;:.;;;;:,:.;:.:.:;.;:.; :.:.;:.;:.:.::.:.;:.;;::. <br />~:C~fl:~' .. .: ::: `<:~ ` ~~; :: :;< ::; :: ::~: :: : :.:~ : . :: :: ::;:<:><::»<:»>::>::::::::>::>::::»~>:;:::::::»:<:: <br />::::::::::;:.:::.~.~~~~COI..f~: C~~:~t~~A~'~'~.:.:.;~ ::::::::::::: :.:::::.~:.::.;:.;.::::: <br /> <br />......................:::::: :.:::::::::::::::::::::::.:~:.;::.:;.:;:.:.;::.;:.;;::.;:.:.;:.:.;;>::>::::> ;: :;.:.;:.:.;>;:.;:.:.>:.;:.;::.;;:.;:.>:.;:::. <br />:>::>::>::>::;:>:<:»::;::::~;:.;:.; :.::.::::: <br />::::::::::.:~:::::::.;:.;:.;::;:::::. <br />.. <br />::>::»::>::»::>::::»»>::::;::::>:::>::>::>:: .;;:.::.;...: ..:_: <br />::.: : : : . ::. <br />. :.:. <br />: A~.~.:: <br />;:::;:: ........::: <br />..... ;:: : : >: <br />:: .. .. ..:.... <br />.;: ::: <br />.:. ;:;;.: <br />.: ~`.::. <br />........... .... >::.........:»... ... ...,.,:...:.,:.....<.;:.;;:::::::::.: : : <br />... .. .. <br />:.:. .: . :: . . . :: ::::::::::. :.;:.::::: <br />;:.: :. : . :.: ... ..: .. .:: ;::::.:::::::::::.::.;:. <br />:..'~'~~.~~± . <br />::::::::::::::::::: <br />;~';f~~~>::>::>::»>::::>::::> <br />: <br />:> <br />:> <br /> <br />' m e.l C'. raw~il <br />8 <br />,/Y1 :: <br />: <br />: <br />:: <br />: <br />5g -o~ ~39 <br /> <br /> <br /> <br /> <br />ESTIMATED TOTAL GROSS MONTHLY HOUSEHOLD INCOME <br />If rent + utilities is greater than 30% of the total gross household income, displacee must complete <br />income verification form and provide complete state and federal returns. <br />SPECIAL RELOCATION NEEDS OF THE RELOCATEE: <br />UTILITY OF DISPLACEMENT DWELLING: <br />REPORT OF PERSONAL INTERVIEW: <br />Right of Way Agent Date <br />Form 101 (6/95) RELOCATION <br />RESIDENTIAL OCCUPANT INTERVIEW <br />