Financial- Marion Co. Housing Authority

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~~ ~ Appendix I l, llandbook 1378 CIIC-! Claim for Moving and Related Expenses -- Families and Individuais U.S. Department ot Housing and Urba~ Development Fo- AganCy Namr o~ Aqency: Prqxt Nam~ a NumDa: Gas~ N~mDer: Use Only: \ ~ ~_~ ~ Y s Publle Reporting Burden for this collecOOn of inf adon is esOm tedtoaveraqe 0.5 hours perresponse. ~nduding the ome lorreviewirg instrucuons, search~ng existing data so~~rcPs, gatharing and maintaining the data needed, and compleUng and reviewing dia collecuon ol inlwmation. Send comments regarcSng th~s burden estimate a any other aspect ot this colled'an nf inlormaoon, includng suggesoons for redudng this burden, to the Reports Management Otficer, Oll~ce of Inlamation Pdicies and Systems. U.S. Department of Nousing and Urban Devebpmen~ Washington, O.C. 20410•3600 and to tho Ottice ol Managemen~ a~~d Budget, Papervvork Reduction Projed (2506-0016), Washington, O.C. 20503. Do not send this completed form to either of these addressees. In struet(ons: This daim form is tor the use ot famil"~es and individuals ~pplying lor payment of moving and related expenses. rou may appry ~or eivier ( i) a nxec allowance, or (2) an am~unt to cover Me actual movin9 and related expenses inwrred (as described on page 2 of this lam). A claim for acNal expenses mus; be supponed by reeeipts or other evidence. The Agenry will ezplain the diHerences between the two rypes ol payments and will help you complete this form If the full amount of your ctaim is not approved. C~e Agency will provide you with a written explanatan of tl+e reason. II you are not satisCred with the Agency's determinacon, you may appea~ that determinauon. The Agency wiU explain how to make an appeal. i. You~ Name(s) (You a~e uu C~a~mam(s)) ~ ta. Present MaiGnq Address(ts) 1 GaimanKs) 14,_~1 ' 1b. TNeplwn~ Numba(s) ~ ,_ ~ ~ a.c~ ~ ~aY~ ~_ `I~ ~~~ ~y~ ~ ~ ~ ~~~~ 2 Have AII MemDers ot [he Household Moved to the Same Dwelling? I~es ~7 No ~Y ' aS'~ G (11'No' list the names of all mcmbers and the addresses to which they moved in the Remarks Settan.) ----- ---- ---- - How Many Rooms Wu It FurrusMd wiC~ VYhsn Oid Yw ~ ~' I Yow Own Furrwtun? I Mow ~o Tnis UMt? Owel+rq ' Address (Mdude Apartment No.) Oid You Oavpp. _ 3. Unit That You ;~~ ~~~~~~ 1 \,~ L,Yes ~No ~ S~ Moved From :~~ Q v _ ~% i d. Unit Thal You i 1 ' E=cludinp Wtnrocros. Moved To hallways anC cbseb. S. Is This a Final Claim? es ' No 6. Computallon of Pa/ment (ca-~~~e~e hcm W a 6D1 . ~ " ~~ _ pcm----- (t) WSoving Cost (2) Trans~onaoon Cost-Families and Individuals (3) Cost of Insurance Cove~ing Move anda Storage (a) Stora~e Cost (Comp:~te Item 10 on paye 2) -~ (5) Other (Explain in Remarks Sec6on) % -_~ (6) Total Amount ol Claim ~Cors~:lt Aqency I~r amount of li:ed a~bwance) i S --------~~ ---~-- (7) Amount ?reviously Revsivad. i( any ~ ~r OMB Approval No. 2506-00/6 (Exp. t ~i30~92) S Is (8) AmOU(1t RGG:JCSI~d (S~DUatt line (7) I:cm li.~e (61I ~ S i S I S 7.CeHit;estlon Hy Claimanl(s): I certiy that this daim and suppoAing inlormatan are true and complete and that 1 have not been paid la lhese expenses b ar»• other sauce. 1 as~c thai the ar.+ount on line (8) ol Item 6 be paid directly to ~me f~the contraca-(s) (as specilied in the Remarks Section) S~~nature(s) d Cla,~a~tt(s) a Oace X fatse cla~ms and statements. Convicaon may resule in criminal and/or civd penalties. (t8 U.S.C.1001.10~0,1012:31 U.S.C. 9%29.38~ To Be Completed by ~ho Agency ! 5~ raw~e ' Name (Tyce or Print) Payment Acuor A~~:nt oi Pay^+>m 9 -••---~--- --- ----... .. _ _ ... . .. . . _.- --- ---- -- • -- - ~ ~ 8 Recommendt~d ~ S ~ I ~ 1 - -- --- --..-..-- -- - - --- - ~ - - - ~ - -- - - - -- -- --- --- ~ e nPao~ed s i ~ i_ Page t o: 2 W. Fxad Albwanc~ ~ 6b. Acwal Movinq Erpenxs ~ Fa j ~S Oate formHUO-40054 (ti5. ret Nandbook t3.