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Oregon Department of Transportation <br />~~~~~f -~~~ ~' ,~ `~~ 91~' r~~~~ ~JG <~ <br />~~ /~ ~(G!~ RELOCATION <br />RFpLACEMENT HOUSING <br />Pay To: ~ A I / ~ <br />~-C.~l.~-~ <br />Mailing Address ~ ,~ ~ ~ ~0 <br />I ~W~ <br />C~aimant's Name <br />~~~ ~~uer ~~ c~a~m a repiacement housing payment, i must purchase or rent, and occupy <br />a decent, safe, and sanitary dwelling within 12 months after displacement. I must <br />submit all 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 Supplement: $`~~'~Q, ~ o Price Differential $_____ <br />Down Payment $_____ Inciderital Costs $_____ <br />Incidental Costs $ 33. oo Increased Interest $_____ <br />Total: $ y~(~3.dv Total: $_____ <br />On y~~ ? I(We) moved/will move to the replacement dwelling. Attached is a copy of <br />the rental contract/ proof of ownership/ closing statement showing the non-refundable <br />fees/ incidental costs paid. To the best of my knowledge, this property meets the <br />~equired standards for decent, safe, and sanitary dwellings. This claim is made on the <br />basi of / ad Its nd _____ children who are regular members of the household. <br />~~l ~'~s ,/9 7 _ <br />Date Claimant <br />- CLAIM <br />Oate Claimant <br />Date <br />rccruy~tMtN I rKUNtK ~ Y CERTIFICATION <br />The replacement dwelling was checked on ~ F~~ and meets the standards for <br />decent, safe and sanitary housing. The claimant is/will be in occupancy and has <br />furnished proof of the right to occupy the dwelling. Payment in the ount of <br />$ 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 />~c„_._ ~ 1 S <br />Reviewers Signature Date <br />RELOCATION <br />REPLACEMENT HOUSING CLAIM <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP No. <br />