Financial- Marion Co. Housing Authority

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. ~ Claim for Moving and Related Expenses -- Families and Individuals Namu o~ Apency: U.S. Department ot Housing and Urban Development Project Nam~ a NumDer: c:ase nurt+oe~: Use Only: {~ ~ 1 PubllcReportingBurdenlorthscollection linfama6onis s6matedtoaverage0.5h sperresponse,~ndud'ingthetimelorreviewinginstrvcaons.searching e~isting data so~~rces. gatharing and maintairnng the data ~ ded, and complebng and reviewing tho wl~ecoon of intorma6on. Send comments regarcLng this burden estimate a any other aspect ot this collectan ~I intamaoon, includn9 suggestons lor reducing this burden, ro the RepoRS Management OHicer, Office of Inlormation Folicies and Systems, U.S. Department ol Housing and Urban Devebpment, Washington, D.C. 20410-3600 and to Iho OHice ot Management ar~d Budget, Paperwork Reducuon Projea (2506-0016), Washington, D.C. 20503. Do nct send lhis completed form w either ol these addressees. Instructlons: This claim lorm is fa the use ot lamilies and individuals s+pplyiny for payment of moving and related expenses. You may appy ta e~ther ( t) a nxea allowance, or (2) an amount to cover the actual moving and related expe~ses incuRed (as described on page 2 of this fam). A claim for acl~al expenses must be supponed by receipts or other evidence. The Agency will explain tlie diflerencea between the Mro rypes of paymenu and will help you complete this fam. If the lull amount ol your ctaim is not approved, the Agency witl provide you with a written explanatan of fhe reason. If you are not sacsl'~ed with the Agency's determinaoon, you may appeal that determina6on. The Agency wi4 explain how to make an appeal. i. Yow Name(s) (You are me C~a~mam(s)) ~~a. Prasent Ma~tinp AdOnu(as) ol Cla~rtwnqs) 1D. 1 fllpnpn! NumD9r(S) .~% \1..~..~.~_~J..~~ ~ 1~` 1~1~ ~ i 2. Have All Members of the Household Moved w the Same Dwelling? Yes ~_ No (If 'No,' list the names ot all members and the addresses to which they moved in the Remarks Section.) ---- -- -- ----'--- -"--~ How Mary Rooms Wu II FurniShed w~ln When D~d You ~„e~;,~.9 ~ ____ AEdress (indude Aparvnant No.) IOid You Oaupy? ~ I Yow Uvn furniNrs? ~Mow to This U~~t2 3. Unit That You e I~~.r~~~ ~Yes ~No I ~ ~ I~~ Moved From ~~ ,~~..~L~ ~ "~' `f - - i t Unit That You ~ I ' E:cWdiny battuooms. Moved To ~ ___ ~_ hatlways an0 cbs~u. 5 Is This a Final Claim? es ' No 6.ComputationofPayment (cor+a~etel~em6aa6b1 ~ Item I W. Fixed Albwanc~ 6b. AcNal Mov~n Erper+saa 1 (t) Noving Cost ! S S (2) Trans~ortation Cost-Families and Individuals (3) Cost of Insurance Covoiing Move andla Storage / i~~ ~ (a) StoraSe Cost (Comp~te Item 10 on paye 2) v//~ / / --~ (5) O~her (Explain in Remarks Sec6on) / ~--- (6) Total Amount of Cloim (Cors~~t A~ency Ix amount of fised a~lowance) i S C' /'~ d~ ~= s -1.1~_-- (7) Amount ?revious~y Rec~ived, if any For (8) Amount Rc ~~CSted (Subtract line (7) t:om li;w (6)) I S i S I S 7.Certit~catlon By Clalmant(s): I ceR+y that this claim and supporting information are true and complete and ehat 1 have not been paid for these expenses by any other source. 1 a~c that the amount on line (8) of Item 6 be paid direcdy to ~me fJ the contraclor(s) (as specified in the Remarks Sectan). yana~ure~s)o~Clam ~s a!e: ` . ~ ! ~ ~ ~ - - X Warning: HU ill prosecute fa e claims and statements. Conviction may rosult in criminal and/or civ~l penalties. (16 U.S.C.1001,1010.1012:31 U.S.G.3i~9, 3eoz) To Ba Completed by tha Agency PaymEnt Acuo^ ` ATount ol Pay^+ant ~ S~qr.atwe _ ;.... . ----t---•-----•-- _._ _ -` 8. Recommend2d ' S ~ ~ ' --'.-.--'.._._ .. .- - -• --_._ . _.~.__ .__~~---- .....-...._. ~.~ . 9. Approved 5 Page t ot 2 ~ Appendix ll, Ilandb<wk 1378 CUC•i ~i~ -tr OMB Approval No. 2506•0016 (Exp. t t/30~92) Name (Tyoe or Prim) I Dare _ _a _ ~ I I _ _ i lorm HUD-40054 (1/52) rel Handbook t3iE