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~5;'2~1'199'r 10:2~ 5~~-297-2835 HANN~ ~VICELDOi~iNE'v' P~GE 0~ <br />'`'L'AIM FOR COSf TO REESTABLI'S'~ <br />SMALL BUSINESS, FARM OR NPO <br />Pay To: <br />Address <br />City/State: <br />Claimant's Name: O 4wner ^ TeF-ant <br />Agency: <br />Project: <br />File ~: <br />I HEREBY CL.AIl~i 1'HE FOLLOWIlVG COSTS ACTUALLY INCURRED IN RELOCATIIYG AND REESTABLISffiNG MY <br />SMALL BUSIl~iESS, FARM OR NON•PROFIT ORGANI7.ATION. I HAV~ ATTACHED ACI'UAL RECEIPI'S TO YERIFY <br />MY EXPENSES. I HAVE INCLLTDED WRiTTEN SUPPORT' OF .a-LL ESTIMATES. <br />MY CI~-IM IS BASED ON THE FOLLOWIN(3: <br />Repairs or improvcmcnts to the replacement property as required by Federal, Slatc or locai law, S <br />cod~ or ordinancc. <br />Modificatfons ta the nplacement property to accommodate ttic business operation or makc the $ <br />replu~ement structures suitable for conducting the business. <br />Canstruetion and installation voats foc exterior sig~ing to edvenise the business. <br />Provision of utilities from right of way io impmvementa on the replaccment site. <br />Redecoration or replacement of soiled or wora surfaces at the replacement Aite, such as paiut, <br />panelling or carpeting. <br />Licen~es, feas aad permits when nae paid as part of moving expenses. <br />Adverti~ement of replacement location. <br />Prof~.RSional services in connection w+ith the purchase or lease of a replacemen[ si[e. <br />Estimated in~eased costs of operation during tLe first 2 yesrs at the replacement site for <br />sucb itcros as: <br />A. Lease or Ieai81 chuges <br />B. Persoaal or real pcopcrty t~cs <br />C. Insurance premiums <br />D, Urility charges, ezcluding impact fees <br />impact fee or one time a4sessments for antiapated heavy utility usage. <br />Otper (txplain~ <br />'1'OrI'AL REII-~iBURSEMENT NOT TO EXCEED S1a,000 <br />Qaimaut Signaturc Date <br />$ <br />E <br />S <br />S <br />~ <br />AGF.NCY APPROVAL <br />Comments to suppon claim: <br />Amount Approved• S <br />Relocation AQent Date Ageacy Ropresentaave Date <br />