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Oregon Department of Transportation <br />. i~..- ~ ~ --A <br />p emen ousing 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 />'7' / <br />Pay To: ~~ <br />Jcs Q ~ ~ E <br />Mailing Address r, t 1 <br />( ~ ~- `1 1~.~ ~ Cj-e c -F ~~{. ~ ~ <br />~c~~~e m G 7~'02 <br />Claimant's Name <br />In order to claim a re lac t h <br />CLAIMANT MUST COMPLETE THIS SECTION <br />(Tenants) (Owner-Occupants) <br />Claim for: Claim for: <br />Rent Supplement: $_''~.~D Price Differential $_____ <br />Down Payment $_ - _ Incidental Costs $_____ <br />~ <br />Incidental Costs ~$ 1~ ~~ Increased Interest $__ <br />_~---~ <br />Total: $ ~ ~ Total: $ <br />On 3=`~~_, 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 __ 2_ adu s and ~ children who a regular members of the household. <br />~ _ ~ - -~ 7 ~~- ~l' ~a~~l~ <br />aima~t Date laimant ate Claimant Date <br />. ~~~~~ <br />/ ~ ~~~ ~~9~L> <br />RELOCATION <br />REPLACEMENT HOUSING CLAIM <br />ncrv~~CMCN I rK~rtK ~ Y C;ERTIFICATION <br />\ <br />$ <br />$ E. A. <br />$ E. A. <br />~ <br />~1 <br />Reviewer's Signature Dat <br />~ ~ ~-~ ~` ~ Ca-~,en ~E~~ <br />~/0 5 ~C.u~ i ty ~,~~F <br />The replacement dwelling was checked on ~ y~ ~ 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 />$~ Z~ ~ 0o may be made. , <br />-u~'. ~~~CLC.Ec~- ' 9 7 <br />E. A. Agent's Signature ate <br />Form 106 (1/14/95) RELOCATION <br />REPLACEMENT HOUSING CLAIM <br />