Financial- Cromwell, Samuel (Previous Tenant)

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~ Oregon Department of Transportation Pay To: Mailing Address ~ a3`7 -eS~vi~ew (~r S `~C P-7o 9~~va ClaimanCs Name r..~ RELOCATION SCHEDULE MOVE CLAIM File No. Name Sedion Highway County FAP No. I I am the displaced occupant of the dwelling at ~~ (~ Q~~ ~~ ~ . My claim is based on a room count of ~~~2 and is in the amount of $___y~(), W. I elect to move myself and receive an amount based on the number of rooms as established by the Right of Way Agent at the time of negotiations. Number of 1 2~' 3 4 ~ Plus Rooms Unfurnished $300 $500 $700 $825 $125 for each (Relocatee additional room owns furniture) Furnished: $275 for the first room plus $40 for each additional room, . (Relocatee does not own furniture) ~ ~ Exceptions: 1. Person whose residential move is performed by the agency receives $50. 2. Move of a mobile home from the displacement site, actual cost. A reasonable amount may be added for packing and securing personal property for the move at the agency's discretion. ~, 3. Occupant of a dormitory receives $50. 4. Non-occupants of the dwelling, such as landlords, are not eligible for the schedule move. I understand that, prior to this moving payment being made by the Oregon Department of Transpo~tation, this dwelling must be inspected by a Right of Way Agent and found to be vacant, clean and orderly. I also understand that this schedule move agreement is an alternative to a payment for actual moving costs and related expenses and that I will not be eligible for payment of additional mov~ g claims or utili reconnection costs. I vacated the premises on 5~~/y~9 7 -~ , ~~i '~ ~~ ~ ~/r/9 ~ ~ Room Count of )' certified by: Inspection of the subject property was made on _`~~~J~Qa~nd found to be ant, clean, and orderly. I recommend that the schedule move pay nt of $ b released. ~ r'?~ . . . ~~ ~ ~I Comments to support approval: $ E. A. S Reviewefs Sgnature Oale Form 121 (1/97)