Financial- Marion Co. Housing Authority

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._ ` ~ Claim for Moving and Related Expenses -- Families and individuals Appen~r~ll, Ilundbook 1378 CIIC-l U.S. Deparlment of Housing and Urba~ Development RojaU Name w Number: ~ ~r OMB Approval No. 2506-0~16 (Exp. 11/30~92) Use Only:~~~.~,1~`(l ~ ~ \ \\.., ~, ~ .H_~ ~ 1< ,,; ,r ~ i o.~~~Gl~~ ~ ~'`-1J PublicReportingBurdenforlhisco~lectionol~ntamaUOnisesOmatedtoaverage0.5hoursperrespa~se.~ndudmgthe~metorrewewinginst-ucpons searcn~ng existi~g data so~~rces, gatharing and maintairnng the data needed• and completing and reviewing tho collecbon o1 i~formauon. Send commenu regardng this burden estimate a any other aspect ol this colledion of inlormaoon, includ~ng suggestions fw reducing this burden, to the Reports Management Officer, Ollice of Intwmation Rolicies and Systems, U.S. Oepahme~t ol Housing and Urban Devebpment, Washington. D.C. 20410-3600 and to tho ONice of Management ar~d Budget, Paperwork Reducuon Projea t2506-0016), Washington, D.C. 20503. Do not send this completed fortn to either ot these addressees. Instructlons: This claim torm is for ehe use of lamil'~es and i~dividuals applying for payment of moving and related expenses. You may apply tor either (1) a fixed allowance, or (2) an amount to wver the actual moving and ~elated expenses incurred (as desuibed o~ page 2 of this fwm). A claim for acNal expenses must be supported by receipts or other evide~ce. The Age~q wil~ exptain the diNerences between the lwe bPe` ol payme~ts and will help you complete this Iwm. N the Iull amount of your claim is not apProved, the Agency witl provide you with a written ezplanaCan of the reason. H you are not satistied with tfie Agency's determinaGOn, you may appeal that determinatio~. The Agency wiq explam how to make an appesl. ~ ~a. Present Ma~_6~+pidd!ess(e~Lo~,~~ Us ~ ~b. Telephone Numbarls) t. Your Name(s) (YOU are tne C:aimu+t(s)) i~` y~ ~ _ ~ _ I ~ _ ~ ~I't-.~ t R"12r-~~ For Agency Namu ol Ape~cy_ ~ ~ • E:dudinp badvooms. G. Unit Thal You i hapways and doseu. Moved To ~ 5. Is This a Final Claim? ~s ;_ No 6. Computatlon o( P,syment (wr+oie~e ~iem 6a a 6b1 ~ Itcm_____ I 6a. Fixed Albwante 6b. Attual Movinfl EYOe^us For A~~c Us~ -- s S (1) Noving Cost (2) Trensaortadon Cost-Families and Individuals (3) Cost of I~surance Caveiing Move and~a Storage / (4) Storage Cost (Compf~te Item 10 on page 2) _ ------ ~ (5) Other (Explain in Remarks Section) _ _. ---- - ~ - ~ ,~~ ~ s s (6) Total Amount ol Claim (Cors~~t Agency Ix amouo~ of fi:eC ybwanca) i S ~ I E- `""r"-- ~ Yes No 2. Have All Members of the Household Moved to the Same OweUing . (tl'No' list the names of all mcmbers and the addresses to which they moved in the Remarks SectionJ _. ___.- -Ipw Many Rooms Wu (t Ftxnished w~M When Pd You ~ Address (indude Apanmw~t No.) IOid You Oaupy?' Yow Own Fwniare? Nbve ro TMS UMi? Dwe~+rq . ~t,, 3. Unil ThatYou-;~"~" ~~~~ ~ ~ ~V 'e5 ^No 'Z,~~~~ Moved From ,~~ Q ~- ~ ~`~ i (7) Amount ?reviously Rernived, if any -_-_ ~ _ ~ ' - ------- ---~-------•- I s i s s (8) Amount Re~~ested (Subuaa ~~ne (%) ~~~m ii:,e ~6)) : I 7.Certil~cation Ry Claimant(s): 1 cert~.y that this claim and supporting intormatan are true and complete and that I have not been paid for these expenses by any other source. I ask that Ihe amount on line (8) ol Item 6 be paid direcdy W ~me ~~e contraclor(s) (as specified in Ihe Remarks Section). S~~nawre{s) ol Clamarn(s) 6 Da!e: X ~ ' / ~ ~~~ ~fl~- ~~ Warning: HUD will prosecute tatse claims and statements. Conviction may ~esult in criminal and/or civd pe~altres. (18U.S.C.1001.10t0.10t2.31 U.S.C 3i29.3802) To Be Compleled by the Agency . I Daie ! S~yr.atu~e Name (Tyoe or Print~ _ __ PaymtM Acuo^ ' A~*.ount ol Pay^~°~~ . ----,_._-.L.__- - --- -- _ ~ -^-- ---•._... _ _ -----_;------- ---- ----... . _ 1 I i e Recommended 'S ~ ' ~ ~ ~ _ _----r-' -- --~------- --~---- 9.Approved 5 I i Page t o: 2 lorm HUD-4005d (1/52) rel Handbook1378