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~ <br />Claim for Moving and Related Expenses <br />Families and Individuals <br />~ /~'0 <br />U.S. Dspartm~nt of Houslrq ~ ~ <br />and Urban DsvNopmsrtt <br />OMB Approval No. 250fr0016 (exp. 11l30/90) <br />N~me oi Aqsncv ' ProJect N~ms or NumDer Case Numbe~ <br />~11~r~on Co~nt~ 4~o~,e,,~Au~.~ari-I~ S~~,a~ 'I~Q~mPn~s 3 0`~ <br />Public reportfnp bur0~n for thla collectlon of Informatlon ia estlmet~0 to av~raps 0.5 ~ours pa~ reaponse, Inc~utllnq the tims tor rsvi~winp instructiona, asarcni~p exlatinq Oata aources. <br />patnonnp ~ntl malntdninQ tns oata nsWstl, anC complstinq ~ntl rwl~wlny tM coll~etlon ol Informado~. SsnO commsnb r~parOlnp thit burden ~stfm~ts or any othsr aspsct ot this <br />coiieetlon ot Informatlon, IncluOinq supp~stlo~a for n6ucinp l~ts buWsn, t0 ths R~port~ Manapem~nt Otflcsr, Offic~ of InfOrtn~tlon Pollcf~s anA Syst~ma, U.S. D~partment ol Housinp <br />enC UrOan 01vs10Dm~nt, w~shinqton, D.C. 20at0.'i800 ~ntl to th~ Offlc~ of Manapsmsnt ~nd Budpet, Papsrworr ReCuctlon Pro)set (2508-0078), Wuninpton. D.C. 20509. <br />Priv~ey Aa Notlc~ Thls Infortnatlon is needed to determine whether you are ellylble to receive a payment for movinq and related expenses. You are not required <br />by law to fumish thls Intormation, but if you do not provlde It, you may not receive any payment tor these expenses or it may take lonqer to pay you. This <br />information fs bein9 cotlected under the suthortty of the Unifortn Relxatlon Assistance and Real Property Acquialtlon Polkles Act of 1970. The Intormation may <br />be made available to a Federal aqency for review. <br />Instructbnc This claim tortn fs for the use of famlliea and fndivlduala applylnp for payment ot movinq and rslated sxpensea. You may apply for either (1) a fixed <br />allowance, or (~ an amount to r,over the actual movlnQ and rolated expensea Incurred (as described on paqe 2 of this fortn). A clalm for actuai expenses must be <br />supported by recelpts or ot~er evfdence. Tha Aqency wlll explaln tha diffarencea between the two types of payments and will help you complate this fortn. If the <br />tull amount of your clalm Is not approved, the Apency wlll provide you with a w-itten explanation of the reason. If you are not satisfied with the Ayencys <br />aeterminatlon, you may appeal that detertninatfon. The Apency will explafn how to make an appeal. <br />1. Yuur N~me~s) (YOU u~ the Clalmant(sp ta Pns~nc Mailinp AOdr}sa(ss1 ot Cia~mant~al 1D. T~ISp~or~ NumbsQs~ <br />-~- .~ (\l.L1C7 ~T a m~,rrt~.QOM3o9 <br />...~ os~ E, L.oP~z a.,$ N~..h~s~. G <br />~„~o r>o_ ~~~~ <br />2. Have All Members of the Household Moved to the Same Owelling? '~ Yes ^ No <br />(If "No", list the names of all members and the addresses to which they moved in the Remarks Section.) <br /> <br />Dwelliny <br />AtlOroaa ~1nelud~ Apanment No.) Mow M~ny <br />ROOms Dld <br />YOU OceuDY?~ Was It Fumishld• <br />Wlih YWr Own <br />furniture? When DiC Vou <br />Move To <br />This Unit? <br /> <br />3. Unit That You S~~Q~~ ~ <br />a~$ N~~.hS .N~. QO~x 3Cj'1 ~llWl~ f~/ <br />-t~ Yes ^ No <br /> <br />~-~~ <br />Moved From S~~m ~~ q~3o I , <br />4. Unit That You ~E~ccludinp Dat~rooms, <br />MOVed TO na~iways ana e~oss~s. <br />5. Is This a Fina! Claim?~(Yes ^ No (Ii "No", Explain in Remarks Section) <br />8. Comautatlon of Parment (Complete Item 6a or 6b) <br /> <br />Item 6a. Fixed Allowance 6b. ACtual Moving <br />~pe~~s <br />For Aqsncy Uss Only <br />(t) Moving Cost S a <br />(~ Transportatfon Cost - Fam(lies and Individuals <br />(3) Cost of Insurance Covering Move and/or Storage <br />(4) Storage Cost (Complete Item 10 on page 2) <br />(5) Other (Explain in Remarks Sectionj <br />(6) Total Amount of Claim ~ca,sw~ ~oe~er ~a a~w~m oi n:sa a~ww.~cs~ S ~ $ $ <br />(~ Amount Previously Received (If any) <br />(8) Amount Requested (Subtract line (~ from Line (6)) 3 3 $ <br />7. CeitlHcaUon By Clalmant(s) <br />Wsminq: If you knowinqly maks fals~ statsmsMS on this form, you may b~ subjsct to efvfl a cNminal p~~altf~s unds- Sectfon 1001 of Title /8 of ths <br />Unk~d Statss Cods. In addklon you may not rocNr~ ~ny of th~ ~mounts clalmsd on this form. <br />1 Certify that this claim and supporting infortnation are true and complete and that I have not been paid for these expenses by any other <br />source. I ask that the amount on Line (81 of Item 6 be paid directly to ^ me ^ the contractoKs) (as specified in the Remarlcs Section). <br />o nw i=amo~arwa 6v o <br />Payment Action ' Amount ot Payment Signature Name (Type or Print) Date <br />8. Recommended S <br />9. Approved S <br />Page t of 2 tor-n HUD-4005d (1/90) <br />ref. Handbook 1378 <br />