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. ! ~ <br />• ~ ~' ~ /`~ <br />Ciaim for Moving and Related Expenses e~ ~~~ o~~~~~ ~ r' <br />Families and Individuals OMB Approval No. 2506-0016 (exp „~o~so~ <br />For Agency Use Only Case Number <br />~ Pioject Name o~ Numbe~ <br />Name ol ApencY ~ I A ~~~' <br />~ ~ ~. ~1~~~~~~~;`I~~~ ~L'I~~CY ~~~7t~'~~ti1Ni1~~ (x)~v~ ~~' <br />I~~clc;o~~ ~'~~~~~Z~1~~ ~vc~~~~~~~ .. . <br />, I f ~ ~%~. <br />PuDiic ~eponin0 Durds~ lor t~la coliection ol inlormatlon ia satimatsd to averape 0.5 hours par reaponse. inclu0i~p the time for reviewinp inetructione, searcninp existinq Oata sources. <br />pstnerinp and msintalnlnp 1hs Oata nesOSd. and com0~stinp and revlswinp t~s colleclion of Information. Se~O commsnt~ rspar0inp t~is burden satimate or any ol~er uDect ol this <br />collection ol Infortnation. Includlnp luppestions lo~ reCucinp this bur0en, to lne RepOrts MlnaQement Ollicer. Otlice o~ Inlortnation Policies and Syalems. U.S. OeDartment of Hous~~g <br />a~o UrDan OsveloD~~~• Wuninpton. D.C. 20410~7600 and to tne Office of Maneqement and Budpat, PaOenvork Reduclion Pro~ecl (2506-0016), Washinqton, D.C. 20503 <br />privecy Act Notkr. Thls Intortnation is needed to detertnlne whether you are ellpible to receive a payment for moving and related expenses. You are not requirea <br />by law to furnish this intormation, but if you do not Dro~ide il, you may not receive any payment lor these expenses or it may lake lonper to pay you. This <br />intortnatlon Is belnp collected under the authortty of the Uniform Relocation Assistance and Real Property Acqulsitlon Policies Act of 1970. The infortnation may <br />pe made available to a Federai agency tor review. <br />Inshuabns: This Claim form fs for t~e use of tamilies and indivitluals apP~Ying for payment oi moving and related expenses. You may apply for either (i) a fixed <br />allowance, or (2) an amount to cover the actual moviny and related expenses i~curted (as described o~ pape 2 of this form). A clalm for aCtual expenses must be <br />supported by receipts or ot~er evidence. The Apency wlll ezplain the dilferences between the two types of payments and will help you complete this form. It the <br />tull arnount of your claim Is not apOruved, the Agency will provide you with a wAtten explanation of t~e reaaon. ~~ you are not satisfied with the Agencys <br />determinatlon, you may appea~ that detertnination. The Apency will ezplain how to make an appeal. <br />ia. Presen~ Mailinp AOtlress(es) ol Claimant(sl tb. TsIeD~~e Numbe~(s) <br />t vour hsme{s11VOU ~n the Cla~mant(sl) <br />u ~ r(l ~ Q~1S~~tl :~e~a~ P,~n~-~~^~t S 1 I ~ hcx~e~ <br />t~; c.~ac- ~~g N; h 5~ t~,~ ~~~- ~ <br />2. Have All Members of the Household Moved to the Same Dwelling? .~ Yes ^ No <br />(It "No", list the names of all members and the addresses to which they moved in the Remarks Section.) <br />Mow Many Was It Fumfst+e0• Wnen Did Vou <br />Dwelllnp AtlOrase (lnclude AD~~msnt No.) Rooms Dia Wlth Vour Own Mrne To <br />~' Fumilure? This Unit? <br />You OccuDY~ <br />Sen~:~or A q}5. ~u~d~ o ^ No 2~ - I~ -~j <br />3. Unit That You ~1~ ~~~h S~, ~C ~a-~ ~ ~ Yes <br />Moved From ~..~ c~~ 30 ~ ` <br />~ Excludinp Dathrpoms, <br />4. Unit That You naliwaya an0 cloxts. <br />Moved To <br />5. Is This a Final Claim? (~„ Yes ^ No If "No", Ex lain in Remarks Section <br />6. Comput~tloo ot P~ymsnt (Complete Item 6a or 6b) <br />6a. Fixed Allowance 6b. Actual Moving For Aqsncy Uss Only <br />Item Expenses <br />s S <br />(t) Moving Cost <br />(2) Transportation Cost - Families and Individuals <br />(3) Cost of Insurance Covering Move andlor Storage <br />(4) Storage Cost (Complete Item t0 on page 2) <br />(5) Other (Explain in Remarks Section) <br />(6) Total Amount oi Claim ic«,sw~ n ency ~w amouM ol tixed allowance) $ <br />c ~CJ~ ~ ~, `~ $ ~ <br />(~ Amount Previously Received (If any) <br />~ S $ <br />(B) Amount Requested (Subtract Line (~ from Line (6)) _ <br />7. CsrtlNutbn By Clalmant(s) <br />Warnlny: 11 you knowingly meke false statsmsnta on thls form, you may be subject to elvil or criminal penaltfes undsr Sectlon 1001 0~ Tltle 18 of the <br />Unltsd Statss Code. In addltlon you may not recNvs sny of ths emounts clalmsd on thls form. <br />I Certlfy that this claim and supporting information are true and complete and that i have not been paid for these expenses by any other <br />source. I ask that the amo nt on Line (8) of Item 6 be paid directly to ^ me ^ the contractor(s) (as specified in the Remarks Section). <br />Date <br />Sipnawrael ol C~aims t(sl <br />~ ~f'"c ~ ~~' ,:~~~-z ~_ _ ~ _ <br />TdBe~Complated By Agency ' <br />Paymenl Action Amount o~ Pa~•ment <br />8 Recommended~ S <br />y Approved <br />Signature <br />I <br />_ + _ <br />Name (fyDe or Print) <br />Oate <br />Page t o1 2 <br />form HUD-40o54 (1/90) <br />ref. Handbook !379 <br />