Financial- Marion Co. Housing Authority

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~rl'0 ~ ^ ~laim for Moving and Related Expenses ~ a~~ p~~ ~w , r Families and Individuals OMB Approval No. 2506-0016 (exp t t/30~90) Nama ot AQsncy Use numoer ~nG Y ~ c~(1 Cc9.~~ ~~~~'~G~ I 5ex~c~~ I~4v~1 P~b11e repoRinp burd~n fo~ th1D cOllottion of Infortnatlo~ la eatimatsd t avsnp~ 0.5 noun par rospons~ includlnp th~ tim~ for rsv~aw~np instruetlona xarch~np exlat~nq Oa~a sources yatherinp u+0 malntdnln0 tns dau nseGSO, anG compietfnp ~nd rwl~v+l~p th~ eollsetlon of Intormatbn. Send commMte nqard~n9 t~~s Durtlsn sstimat~ or any otnsr s~pect o~ tn~s colisc~~on ot Infortnatfon, InelutllnQ auypaetlona tor reduclnp thls DurOen, to tne RspoRa Manapement Ottieer, Ot11es of lnfom+atlon Poi~cies anC Systems, U.S. DeDartment o~ Ho~alnp and Urban D~vsiopm~nt, Wasl+inOton, D.C. 20416~800 and to the Offics of M~napsment ~nd Budpet, Papsrworf~ Rsductlon Proiact (25060018). Waaninpton, D.C. 2050~. Prlwcy Aet Notle~c mis informatlon fs needed ta detertnlna whether you are elipible to receTena fpaY hese axpe aes or&I~t aly taka onpeeto pay younThis Qu'r~ oy law to tumish thla I~formation, but If you do n~t provide it, you may not recelve any paY info~+atlon is bslnp Collected unde~ the authority of the UnifOrtn Relocation Asslstance and Real Property ~4c0ulsltlon Pollcies Act of 1970. The Information may ~in made eval~eb~e to a Fsderal aqency for review• ~nsen~etb~s: Thle clalm fortn Is for the uae of famllfes and fndlviCuals apD~Y~^9 for peyment of moviny and rolated axpenses. You may app-Y tor either (t) a fixed allowance, or (~ an artwunt to cover the actual movi~0 and rolatsd expensea incuned (as deacribed on paqe 2 of t~fa form). A claim for actual expenses must be supported by reoe-Pta or ot~er svldance. The Apency wlll explaln the differoncea between the two rypea of p~ymsnts and will help you complete this ~ortn. If the iull amount of your cl~im la not approved, the Aqency wlll provide you with a written explanation of the roason. If you are not aatiafied wlth the Agencys detertnlnatlon, you may apDeal that detertnination. The Apency wfll explain how to make an appeal• ~p, TsisWwne NumosRel i Yvur 4amNs) (YOU an lh~ Ctalmsnt(s~) ta Prosent Mdlinp AOdresa(ea) of Claimantls) . ~ ~ « •(lJV1 ~ v, . . ....- - - y~ t~ 2. Have All Members cf the Household Moved to the Same Dwellin9 ~ Yes ^ No (If "No", fist the names of all members and the addresses to which they moved in the R Hmark~Section.) W~ It Fumianea• wns~ o+a ro~ ACCress (Includ~ AD~msnt No.) iiooms DiE Wlth Your Own Move To~ pw~llinp You OCCUDY~~ Fumiture? Thie Unit. C^}a~ ~~h ~ ~ ~ ~ 1 (~ Yes ^ No 3. Unit That You Movad From ~ . ~ ~"~3O ~ ~ 1 ' ExcluCin9 Cathrooms. 4. Unit Yhat YOU na~~w~ys and eiossts. Moved To 5. !s This a Final Claim? Yes ^ No If "No", Ex tain fn Remarks Section 6. Computatbn of P~yment (Complete Item 6a or 6b) 6b. Actuai Moving 8a. Fixed Allowance Expenses Fa Aysncy Uss Only I tem _ S a (1) Movinp Cost (~ Transportation Cost - Families and Individuals (3) Cost of Insurance Covering Move andlor Storage (4) Storage Cost (Complete Item 10 on page 2) (5) Other (Explain in Remarks Section) S~ v0 $ s (6) Total Amount of Claim ~co~so~~ ng.~+er ~w y^«r^+ o~ "^'0 ~1OM/"`a S ` (~ Amount Previously Received (If any) --~ s s a (8) Amount Requested (Subtract Line (7) from Line (6)) i. c.rt~tk,ta~+ sr caima~ecs~ Wsrning: If you knowinqty meks tslse stat~mMts on this fortn. you may ba wbjeet to civll or crfm~na~ Pe^alt~~s ~^dK Sect~o~ ~001 of Titls 18 of t e Unksd St~tss Code. In eddltbn you may not rscNv~ ~ny of the amouMs claimsd on this tam. 1 Certlty that this claim and supporting information are true and complete and that I have not been paid for these expenses by any other source. I ask that the amount on line (8) of Item 6 be paid directly to ~ me ^ the contractor(s) (as sPecified fn the Remarks Section). _ n.~. SiQnature(s~ of Clalmanpsl ~. . n ~ rJ / i~ / To B~Cor~plstsd e aqsncy Payment Action Amount ot 8. Retommended~ S Name (fype or Print) Date 9. ApDroved S form HUD-40054 (1/90) Page t of 2 ref. Handbook 1378