Laserfiche WebLink
.~ ; ,~„ ,..r <br />Oregon Department of Transportation <br />RELOCATION <br />REPLACEMENT HOUSING Ct_Ainn <br />Pay To: • <br />~nl~ <br />Maiiing Address ~ I ~~ ~ ~~ <br /> L ~ <br /> <br />ClaimanYs Name -~ 1 <br /> <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP No. <br />In order to claim a replacement 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: $ l~a_~~ Price Differential $_____ <br />Down Payment $_____ Incidental Costs $_____ <br />Incidental Costs $~~ N'~ Fe~-- Increased Interest $_____ <br />Total: $~1~00 Total: $_____ <br />On _____, I(We) moved/will move to the replacement dwelling. Attached is a copy of <br />the rental contract/ proof of ownership/ closing statement showing the non-refundable <br />fees/ incidental costs paid. To the best of my knowledge, this property meets the <br />required standards for decent, safe, and sanitary dwellings. This claim is made on the <br />basis of __1__ adults and _Q__ children who are regular members of the household. <br />I Claimant <br />Date Claimant <br />uate uaimant <br />Oate <br />KtNLACEMENT PROPERTY CERTIFICATION <br />The replacement dwelling was checked on / n/~~~ and meets the standards for <br />decent, safe and sanitary housing. The claimant is/will be in occupancy and has <br />furnished proof of the right to occupy the dwelling. Payment in the amount of <br />$ 51~.~ _ may be made. <br />$ E. A. <br />Q <br />.p E. A. <br />Q <br />•P E. A. <br />Form 106 (1/14/95) <br />AgenYs Signature Date <br />Reviewer's Signature ~ate <br />RELOCATION <br />RFPI A(`G11A~~IT un~ ~c~~~~ n~ ~~~~ <br />