Financial- Cromwell, Samuel (Previous Tenant)

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~,.. Oregon Department of Transportation Pay To: MailingAddress ~~~ a~~v,~~ ^r ~ ~~~~0 I K. IU ~ ~a l~n-~ . b 12 9~3va; ~ Claimant's Name RELOCATION SCHEDULE MOVE CLAIM File No. Name Sedion Highway County FAP No I am the displaced occupant of the dwelling at .S(~O~,~a ~$~ ~- ~ . My claim is based on a room count of ~~~2 and is in the amount of $ S~,w . I eleCt to move myself and receive an amount based on the numberof rooms as established by the Right of Way Agent at the time of neyotiations. 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: I 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 Depa~tment of Transportation, 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 ~~~~9 7 ~ ~/ ~/ .~-/~ `~ i5~. ~ `f~~97 /~, Room Count of~certified by: Inspection of the subject property was made on _~~'~~a~nd found to be ant, clean, and orderly. I recommend that the schedule move payrr~nt of $~~ b~released. ~ Comments to support approval: $ E. A. S Reviewers Signature Oate Form 121 (1/97)