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~ <br />~wr~ /\ <br />/~~ <br />~r <br />OMB Approval No. 2506-0016 (exp. t t/30/90) <br />~laim for Moving and Related Expenses ~ d~ ~~~ ^~ <br />Families and Individuals <br />Name ol Aq~ncy <br />numoer <br />c.~Y ~<r~ c c~:t~~~ ~~<~~~~n~- ~ ~.~cx~ 3~ ~i <br />PuDHc rsponlnp Durdsn for this collection of lormation la ~stlm~tW lo ~npe 0.5 ~oun psr roapons~, lnclu0lnp tM tims for rwlswinp instruetions, searehinp ezistinq Oata aources. <br />patnsrlnp arW mtlntdnlnp tM dau nssaW, an0 completlnp an0 rsvl ths collectlon of Info~natlon. S~nd comm~ntr npWinp t~l~ Durden ~stim~te or any ot~sr upect of t~is <br />couection oi inrortnatlon, includinp suppesuona tor reducinp tnls Durosn, to t~~ Reports Manapem~nt Ottle~r. OHie~ of Informatlon Polleles and Systsma, U.S. D~DU1me^t of Mousinp <br />and UrCan O~wlopm~nt, Wash~n9lon, D.C. 20/143800 and to tM Otfk~ o/ Man m~nt and Bud ~t, P~rwak RWuctbn V-o~set (2508-0018), Washinpton, D.C. 20303. <br />Prlv~cy Ad Notle~ Thia lnfortnation is needed to detertnlne whether you ue e119ib1e to receive e payment for movinp and related expenses. You are nTh~rs quired <br />by law to tumiah this infortnation, but if you do not provide It, you may not reCefve any peYmant tor thsse expsnaes or It may take lonpet to pay y <br />Infortnation la beln0 coilected under the authority of the Uniform Relxatbn Assistance and Real PropaRY AcQuisitlon Policles Act of 1970. The Infortnatlon may <br />be made avNlable to a Federal apency for review. <br />In~bnc Thla claim fortn is tor the uae ot famfliea and Individuala apply~ny for payme~t of movlnp and rolated expensea. You may apply for either (1) a fixed <br />allowance, or (2) an emount to cover the actual movlnfl and related expensea fncuRed (aa deacrlbed on psps 2 ot thla fortn). A clalm for actual expenses must be <br />supported by recelpta or other evfdence. The Apency will szplain the dffferencea bstween the two types of peymenta and wlll help you comp~ete this fortn. If the <br />tull amount of your claim Is not approved. the Ayency will provide you with a written expianatlon of tM roaaon. If you are not satlsfied with the Apency's <br />detertnination, you may appeal that determination. The Aqency wlll explai~ how to make an appea~. <br />~. Your Namsla) (YOU ars ths Clafmanl(s)1 ta. Pnsent Maillny AddnsNss) 01 Cidmant~s) tb. Telephone NumDe~a) <br />:~a~~ H ~ln ~ N`. ~- ~~ci <br />~ ~an~~r~ \ v..w~ r~ ~,~ ~ _Tx`~~n `~_ cxZ ~ ~~ ~ ~r '. 3~5 - n~ ~ ` <br />2. Have All Members of the Household Moved to the Same Dwelling? Yes ^ No <br />(If "No", list the names of all members and the addresses to which they moved in the RemaAcs Sectfon.) <br />How Many Was It Furnished• Wnen Di0 You <br />Dwsllin9 Addross (IncluOe Apartmsnt No.- Rooma Did With Your Own Move To <br />You Oetupy?~ Furniture? T~is U~~t? <br />~~` , C'~ ~ J 1 ~' ~.~ '~ '~j~`~ ~ Yes ^ No <br />3. Unit That You <br />Moved From ~- ~~ G ~ <br />~;~\ ~~c r ~ CX~ C1-1 ~ ~~ <br />4. Unit That You <br />Moved To <br />' Ezeludfnp bat~rooms. <br />hdlways Mtl elONts. <br />5 Is This a Fina! Claim~ ~ Yes ^ No (If "No" Explain in Remarks Section) <br />6. Computatlon of P~ymsnt (Complete Item 6a or 6b) <br />Item 6a Fixed Allowance sb' ~~~SeS~~~9 Fw Aysncy Uss Only <br />~1) Moving Cost <br />(2) Transportatan Cost - Families and ~ndividuals <br />(3) Cost of Insurance Covering Move andlor Storage <br />(4) Storage Cost (Complete Item 10 on page 2) <br />(5) Other (Explain in Remarks Section) <br />(6) Total Amount of Claim Icoeaw~ ~psncy ~or.moum or t~xsd y~owance) <br />(~ Amount Pre~iously Received (If any) <br />s <br />S <br />S <br />a <br />$ <br />(8) Amount ReVuested (Subtract Line (~ from Line (6)) I S I S I$ _ <br />7. CertlHcatlon Sy ClaimsM(s) <br />Warninq: If yo~ knowinyly mak~ falss stetsm~nts on thls form, you may b~ subJect to civil a Mmin~i p~nakies under Sectfon 1001 of Tltls 18 ot ths <br />UNad Sbt~s Cods. In additbn you m~y nol -acNv~ any of thr amouMS clalm~d on this fam. <br />I Certify that ttois claim and supporting information are true and complete and that I have not been paid for these expenses by any othe~ <br />source. I ask anat the amount on Line (8) of Item 6 be paid directly to ~ me ^ the contractor(s) (as specified in the Remarks Section). <br />oace <br />Sipnature~al of partnant(a) <br />~ <br />To Ba Compi~d BY gsncy <br />Pavment Actwn+ Amount of Payment Signature Name (fype or Prfnt) Date <br />8. RecommeneneC~ S <br />9. Approved I S I I ~ <br />Pa e ~ ot2 bmt HUD-40054 (t/90) <br />9 ret. Handbook 1378 <br />