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~r <br />Uregon Department of Transportation <br />Pay To: ~ <br />Mailing Address ~ ,~ ~ ~ ~~ <br />` ~W~ <br />Claimant's Name <br />in order to claim a replacement housin a ment I <br />~ <br />RELOCATION <br />REPLACEMENT HOUSwr ri e~nn <br /> <br />g p y , must purchase or rent, and occupy <br />a decent, safe, and sanitary dwelling within 12 months after displacement. I must <br />submit a!I claims for relocation benefit payments no later than 18 months after <br />the date of displacement. <br /> CLAIMANT MUST COMPLETE THIS SECTION <br />(Tenants) (Owner-Occupants) <br />Claim for: Claim for: <br />Rent Suppfement: $`~t'_~U, ~ ~ Price Differential $_____ <br />Down Payment $_____ Inciderital Costs $_____ <br />Incidental Costs $_33. c~v Increased Interest $_____ <br />Total: $ yB~3-do Total: $----- <br />On y~~ ? I(We) moved/will move to the replacement dwellina AttachP~ ~~ a rnnv „f <br />the rental contract/ proof of ownership/ closing statement showing the non-refundable <br />fees/ incidental costs paid. To the best of my knowledge, this property meets the <br />required standards for decent, safe, and sanitary dwellings. This claim is made on the <br />basi of _/__ ad Its nd _____ children who are regular members of the household. <br />s , 97 <br />aimant Date Claimant Oate Claimant Date <br />rccrv~~civ~ci~ i rrcurtK ~ Y c;tK I IFICATION <br />The replacement dwelling was checked on ~~q and meets the standards for <br />decent, safe and sanitary housing. The claimant is/will be in occupancy and has <br />furnished proof of the right to occupy the dwelling. Payment in the ount of <br />$ may be made. <br />S ~ <br />$ E. A. Agent's Signature Date <br /> <br />$ E. A. <br />~ E. A. <br />Form 106 (1/14/95) <br />~~.-- S 1 <br />Reviewer's Signature Date <br />RELOCATION <br />~CC'~1 A/'`C11AC~IT Ur'1~ ir~~~~~ ~~ w ~nw <br />File No <br />Name <br />Section <br />Highway <br />County <br />FAP No. <br />