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CLAIM FOR COST TO REFSTABLISH <br />~MALL BUSINESS, FARM OR NP' <br />...1 <br />Pay To: Agency:_ <br />Address; p~~~t: _ <br />City/State: File #: <br />Claimant's Name:_ ^ Qwner ^ Ten nr <br />I HEREBY CLAIM THE FOLLOWING COSTS ACTUALLY INCURRED IN RELOCATING AND REESf ABLISHIIVG MY <br />SMALL BUSINESS, FARM OR NUN-PROFIT ORGANIZA'TION. [ HA VE AT'TACHED AC? UAL RECEIPTS TO VERIFY <br />MY EXPENSES. I HAVE INCLUDED WRTfT'EN SUPPORT OF ALL ES?IMATES. <br />MY CLAIM jS BASED ON 'IHE FOLLOWINQ: <br />Repairs or improvemcnts to the r~cplaccment property as required by Fedetal, State or local Iaw, S <br />code or ordinaace. <br />Modificxtione to tbe replacamant }~roperty to accomrno~date the bueinese operation or maka thc s <br />replacement struetures suitable for conducting the business. <br />Constructioa aad in~tellatioa costs for axterior siEnin$ to advertise the business. s <br />Provision of utilitiae from right of way to improvements on the raplacement site. s <br />Redocoration or replacement of soiled or worn ~urfaces at the replacemeat site, such as paint, a <br />paaclling or c4rpatin~. <br />Licansae, faes and permits when not paid as paR of moving ezpenses. s <br />Advartieament of ~placamaat location. S <br />Pmfessional aervices in eonnection with the purchase or laase of a replecemznt ~ite. s <br />Estimated increasad costs of operation during the first 2 years at the replacement site for <br />suc,i~ items as: <br />A. I.ease or rental char~es <br />B. Personal or real property tazar <br />C. Ineurnnca premiume <br />D. Utility chargas, ~xcluding impsct fees s <br />lmpact fee or ona time assessments for anticipated hesavy utility usage, s <br />Other (e:plain} s <br />S <br />TOTAL AEIMBURSEI-~NT NOT TO EXCEED 510,000 <br />cla~~-t s;gna~re <br />Dac~ <br />s <br />Comments tn aupport <br />AGENCY APPROVAL <br />Amount Approved: <br />Relocation Agc~t <br />Date <br />Agency Repreaentetiv~ Datc <br />