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. ' ~ ~ ~ <br />Claim for Moving and Related Expenses ~ tl~~ mp~~ ~w , r <br />Families and Indivitiuals OMB Approval No. 2506-0016 (exp. 11/30/90) <br />For Agency Uss Only ~ <br />ProJect Nams or Numbar Caae Number <br />Name ot ApsncY <br />(11ar~on Co~n~ 4~a,~o.e.n~Au~l~ari-~ Sena-1-~ Q~men+s 3 0~ <br />PuDiic repoRlnp buMsn tor thla collactfon o1 Infortnatlon la sstlmatsd to av~nys 0.5 ~oura pa~ response, includln0 the time for rwfswlnp instructlona, asarchinp e~latinp Oatr sourcas. <br />pafheAnp ~nd m~lntalnlnp the Gata nssdW, ~n0 eompl~tlnp an0 rsvlewiny the collsctlon of Infortn~tlon. SenO commsnts npudlnp thls burdsn sstlmats or any othsr aspect ot this <br />collsctlon of Inform~tlon, Includinp supp~stlons for retlucinp ihle burdsn, to the Reports M~naysm~nt Otflc~r, Otfice of Inlortnatlon Pollclss and Systems, U.S. DeD~rtment of Houainp <br />and Urban DaveloD~~~, W+sh~~9~a^~ ~~~• ~~~~~ ~^d to th~ ONIC~ ol M~n smant and Bud et, Papsrvvork Retluctlon ProJect (2508-0018), Waani~pton, D.C. 20503. <br />Prlv~ey Aei Notler. Thla Infortnatlon is needed to datertnine whether you are eliqible to receive a payment for movinp and related expenses. You are not required <br />by law to fumish thls I~fortnation, but If you do not provfde It, you may not receive any payment for these expenaes or It may take longer to pay you. This <br />infortnation la belnfl collected under the authortty of the Unifortn Relocatlon Assistance and Real Property Acqulaltion Policles Act of 1970. The Information may <br />be made avaliable to a Federal epency for review• <br />lnstrvatbnc Thla claim fortn Is for the use ot famllies and IndNiduals app~ylny for payment of moving and related expensea. You may apply for elther (1) a fixed <br />allowance, or (2) an amoun! to r,over the actual movin9 and related expensea fnCUrred (as deacribed on papa 2 of thla form). A clalm for actual expenses must be <br />supported by recelpts or other evldence. The Aqency wlll explaln the differences between the two types of paymenta and will help you complete this fortn. If the <br />futl amount ot your cleim Is not approved, the Apency will provids you with a writtan explanation ot the reaso~. If you ara not satlsfied wlth the Agency`s <br />aetertninatio~, you may appea~ that detertnlnatlo~. The ApenCy wlll explai~ how to meke an appea~• <br />~. Your Nams(s) (You ue the CWmant(s)) 1~. Pnsent Maillnp Add ss(es) of Clalmant~s) 1b. Te~eD~ons NumbsQs) <br />Se na~c~ ~a me,n-t~oM3o9 <br />~ Ose. E,~-oQ~z a~g N- h~~G <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 Remarks Section.) <br />_ Mow Many Was Il Fumished• When DiC You <br />Dwellinp AEdrssa (lnalude Apartment No.) Rooms Did Wlth Vour Own Move To <br />You Occupy?~ Furniture? Thia Unit4 <br />S~.M~C ~ ~u~i0 ^ No <br />3. Unit That You a,\g N;~-h9 •NG• ~~ 3~ -~Yes g-~-q~ <br />Moved From cJ~~m p~ q~13p ~ 1 <br />4. Unit That You ~Excludinq batnrooms, <br />Moved To nauways and c~ossta. <br />5 Is This a Final Claim~~(Yes ^ No pf "No" Explain in Remarks Section) _ <br />8. Computatbn of P~yment (Complete Item 6a or 6b) <br />6a. Fixed Allowance 6b. ACtual Moving For Aysncy Use Only <br />Item Expenses <br />(1) Moving Cost S S <br />(~ 7ransportatfon Cost - Famllies and Individuals <br />(3) Cost of Insurance Covering Move andlor Storage <br />(4) Storape Cost (Complete Item 10 on page 2) <br />(5) Other (Explain in Remarks Section) <br />(6) Total Amount of Claim tcoos~u noe~cr ~a srtwu^~ m nx°d ri°'"°"cs~ S ~ $ $ <br />(~ Amount Previously Received (If any) <br />(8) Amount Requested (Subtract Line (~ from Line (6)) $ s $ <br />7. CertlHcatlon By ClsimaMla) <br />Waminy: If you knowlnyly maks false stat~msnts on this fam, you may bs subject to civfl w criminal psnakles unds- Saction 1001 of Tkle 18 of ths <br />Unksd Sbtes Cods. In additlon you may not ncNv~ ~nY of th~ ~mouMs claimsd on this fwm. <br />1 Certlfy that this claim and supporting infortnation are true and complete and that I have not been pafd for these expenses by any other <br />source. I ask that the amount on Line (8) of {tem 6 be pafd directly to ^ me ^ the contractohs) (as specified in the Remarks Section). <br />~ i . <br />To Be Compistsd <br />Pavment Actlon <br />8. Recommended~ S <br />Aqs~cy <br />Amount of Payment <br />Signature <br />Name (Type or Print) Date <br />9. Approved I S I I ~ <br />Page t of 2 fomm'i HUD-40054 (1/30) <br />ref. Handbook 1378 <br />