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,~• v ~ ~ <br />Cl~im for Moving and Related Expenses ~ a~~ p~-~t~+~o <br />~ <br />~~ <br />Famifies and Indivi~duals OMB Approval No. 2506-0016 (exp 11l30/90) <br />For Agency Use Only <br />Name ot Apancy Pro)ect Nsme or Number Case Number <br />~~ <br />MCAv ~ r~J~.. ~JaS~~c ~ <br />Pvblic reportinp Gurdsn for thia collectio ot infortnation fa eatima to averape 0.5 houro per responae, Includinp ~ha time tor reviswfnp inatructione, searcninp exiatinq Gata aources. <br />petheAnp and TalntdnlnQ ths Cate needed, anC cOmpletinfl anC re ~ InQ the CdlsCtlo~ Ot fnfOrmstlOn. Ssnd ComTenta rspu0lnq thia burtlen eetfmats or any ot~er aspact ot lnis <br />collection of Inlormatlon, Includlnp suppestiona for rea~cinq tnla burden, to the Reports Manapement Otticer, Otfice ol Information Poilciea and Syetems, U.S. DeDertment ot Houaing <br />and Urban Dwe~opment, Washlnpton, D.C. ?01143600 an0 to tns Oflice of M~nsQement v+d Butlpet. Papsrwork Reductlon ProJect (2506-0018). Wasninpton, D.C. 20503. <br />P~fracy Aet Notfc« Thls Infortnation is needed to determine whether you are eUgible to receive a payment for moving and related expenses. You are not required <br />5y law to fumfsh this Information, but If you do not provide it, you rtiay not receive any payment for these expenses or it may take longer to pay you. This <br />infor,natlon Is befnq Collected under tha authority of t~e Uniform Reiocation Aasistance end Real Property Acquisitlon Policies Act of 1970. 7he information may <br />be made svallable to a Federal age~cy for revlew. <br />Instruetfonc Thfa clalm tortn Is for the use of famllies and indlviduals applyin9 for PaYment of moving and related expenses. You may apply for either (1) a fixed <br />allowance, or (2) an amount to cover the actual rtwviny snd related expenses incurred (aa descrfbed on paqe 2 of this form). A clafm for actual expenses must be <br />supported by receipta or other evidence. The Agency wlll explafn the ditferences between the two types of payments and will help you complete this form. tf the <br />lull amount of your clelm Is not approved, the Apency wlll provide you with a written explanatfon of the reason. If you are not setisfied wfth the Agency's <br />detertninatlon, you may appeal that determination. The Apency wlll ezplain how to make an apPeal• <br />t Your N~me(s) (YOU w the Clsimant(sp 1a. Preaent Malqnq Addrsss(es) of Claim~) „F-_ 7lr~C tb. Tslspnone Numberla) <br />c~C7 ~ ~r ~' ~ -tr V~i~ <br />~Oe. ~o (~ ~ ~~ . 5 ~-e,`M CtK cl~~~ <br />2. Have All Members of the Household Moved to the Same Dwelling? ~ Yes ^ No <br />f II mbers and the addresses to which they moved in the Rema~lcs Section.) <br />(If No , list the names o a me <br />Mow Many <br />Wu It Furnis~ed• <br />When Di0 Yau <br />Dwsllinp Atldresa (Include ADartment No.) Rooms Di0 <br />You OccuDY~ ~ With Your Own <br />Fumiture? Move To <br />T~is Unit? <br /> ~~ `~~ ~ <br />~ Yes ^ No <br />3. Unit That You <br />Moved From ~~~ ~~ ~~3V ~ 1 <br />~l.11~ ~~J ~~,~~ <br />4. Unit Thet You ~Excludiny batnrooms, <br />MOVed TO hallwaya and closets. <br />5 Is This a Final Claim~ (~ Yes ^ No (If "No" Explain in Remarks Section) <br />t(Com lete Item 6a or <br />o. wmpu~.~~ ~f P~ymen P -- <br /> <br />Item <br />6a Fixed Allowance <br />6b. Actual Moving <br />Expenses - <br />For Aysncy Use Only <br />(1) Movin9 Cost S S <br />(2) Transportation Cost - Families and Individuals <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 ~co~s~~~ ~ger+cr +or am«,~i oi n:ea a~~oWa~+~e~ S a O~ u~ $ $ <br />(~ Amount Previously Received (If any) <br />(8) Amount Requested (Subtract Line (7) from Line (6-) $ s $ <br />7. Certificatbn By Claimant(s) <br />Warning: H you knowfnqly maks faiss statsmsnts on thla fo-m, you mey be subject to cfvil or criminal penaltfes under Section 1001 of Titie /8 of the <br />Unksd SUtas Code. In addition you may not rscefve any of the amounts clsimsd on this form. <br />I Csrtity that this claim and suppoAing information are true and compl and that I have not been paid for these expenses by any other <br />source. I ask that the amount on Line (8) of Item 6 be paid directly to ~ me ^ the contractor(s) (as specified in the Remarks Section). <br />Sipnature(s~ ot Cialmant~s~ ~ <br />~ ~,. ~ ;~,.~~; ~,~~,' ~ ~ _ - .~ <br />~o ne wm sa <br />Payment c on or nge~wr <br />Amount of Payment <br />Signature <br />Name (fype or Print) - <br />Date <br />8. Racommended S <br />9. Approved S <br /> i....., w~n .nnc. <br />wa»w.n ~iav <br />Page 1 ot 2 <br />ref. Handbook 1378 <br />