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. r ' ~ ~ ~"'~ ~~\ <br />Glaim for Moving and Related Expenses ~~ ~~~ ^~ 1 r <br />Families and Individuals OMB Approval No. 2506-0016 (exp. 11r30/90) <br />Name of Apsncy <br />Cane Number <br />~ Y ~ ~(~,f ~ ~'~~lr ~G ~~ ~v~n vti. - - <br />rospons~, Includlnp th~ tims tor reviewlnp Inatructlona, searchiny exleNnq tlata souices. <br />Pubifc reportlnp Wrd~n tor thls CollaCtion ol infortnation ta sstlmat~d t avsrape 0.5 houn pv ~~ ~h~~ burden sstlmats or any other aspect o~ tnis <br />patnerlnp ~ntl mdntdnln0 tn~ dat~ ^ssd~d, Nd comp~etln0 and nvbwlnp tM collecllon ot intomutlon. Ssnd commsnla rp~rd p <br />collsctlon of Intormatlon, Inclu0lnq eup9sstlons tor rsducl~0 ~~~s burdsn, to t~e Rsports Man~psrnsnt Ofticsr, Offles ot Intam~tlon Pollciss an0 Systems, U.S. DsDBrtment o~ Noua~~g <br />ment and Bud ot~ P+P~^"ork RsOuctlon Pro)ect (2508-00181. W~a~lnpton. D.C. 205~3. <br />and Urban Dwe~cP~^~~ W~°h~^9~on, D.C. 20t143800 an0 to ths Offlcs ot M~naps <br />prlw~y Acy Notle~ Thie infortnatlon Is needed to Cetertnfne whether you are elipible to ~ement fo~ haee exrpenaes oe ltmay take lonqeeto pay younThis QU'r~ <br />oy law to fumish thls Infortnation, but If you do not proviCe it, you may not receive any paY pcqulsition Policies Act of 1970. The fnformation may <br />infom+atlon Is bsinq collected under the authority of the U~ffortn Relocation Aaslstance and Real PropertY <br />t+~ mede avallable to a Federal apency for review• I for either (1) a fixed <br />~nstructbnc This clalm fortn fs for ths usa oi femllies and Indlviduals appiying for payment ot movinp and -e~ated expenaea. You mey apD <br />2 of thla form). A clalm for sctual expenses must be <br />allowance, or (2) an a~~nt to cover the actual movinp and rofatsd expensea incurred (as deacrlbea on DeOs <br />t Il~amountOf yourpcleifm fahrwt aPPro ~ the Apency wlll provide you iwith a wAtta ez~anstfon o~thearosso~f you are not satfsfied w~th the Agency'~. If the <br />~ that determinatio~. The Apency will explaf~ how to make an ePPe~• <br />d8t9rtT1~~8t~0~1~ YOU miy ~PP~ lb. Tslepho~s NumDehs) <br />t Yoar 4amNs) (`~ou an ~~s Cldmsnl~a~) ta ProssM Mdlinp AOdrss~(~a) ot CINm~ntla) <br />• ~ 1 . <br />H ve Ail Members of the Household Moved to the Same Dwelling7' <br />(If "No", list the names of all members and the addresses to which <br />oW.w~o <br />AdAress (Include AD~rtmsnt No.) <br />Yes ^ No <br />~ moved in the Remarks Se <br />~ How Many <br />qooms Did <br />You OccuPY?• <br />~a~ ~~h ~ ~ ~ ~~ <br />3. Unit That You ~~301 <br />Moved From ~ . ~ <br />4. Unit That You <br />Moved To <br />5. !s Th~s a Final Claim~ ~ Yes ^ No (If "No", Exptain in Remarks Section) <br />g~p~~b~ ol paym~nt (Complete Item 6a or 6b) <br />6a. Fixed Allowance <br />Item <br />Waa It Fumishetl• When Did ~ou <br />Wfth YOUr Own Move To <br />Fumiture? Tnis Unit? <br />(~ Yes ^ No <br />' Excludinp bathrooms, <br />nallw~ys and Wossts. <br />6b. Actual Moving I For Aqsncy Uss Only <br />- s s <br />(t) Movinfl Cost <br />(2) Transportation Cost - Families and Individuals <br />(3) Cost ot Insurance Covering Move andlor Storage <br />(4) Storage Cost (Complete Item 10 on page 2) <br />(5) Other (Explain in Remarlcs Section) <br />S~ ~v $ $ <br />(6) Totat Amount of Claim ~conawi n9encr ~o~ +~^~^~ or nxed yiowancel s ~ <br />(~ Amount Previously Received (If any) <br />--. a s s <br />(8) Amount Requested (Subtract Line (7) from Line (6)) <br />7. CertiNeatlon By Clslmsrrilsl <br />Wernl H u krawinqly maka falss statsmaKS on this form, you maY bs wb1°ct t° civil °r crfminal psnaRies undsr Seetlon 1001 of Titls 18 o t e <br />~9~ Yo <br />Unk~d Stet~s Cods• In addition you msY rwt re~Mr~ ~ny of th~ amouMs clslmsd on this m. <br />I Certlty that this ciaim and supporting information are lrue and complete m d thathe cont acto s) (as specif eden the Remarks Section). <br />source. I ask that the amount on l.ine (8) of Item 6 be paid directly to (~ ^ D.1e <br />S~pnature(sl of Cldmantla) <br />.. ., l n / ~~ / <br />To 8 Coa~lst~o es Aysncr <br />Payment Actlon Amount of <br />8. Recommended~ S <br />Sipnature <br />Name (Type or <br />pate <br />9. ApProved s <br />rom, Huo-aoosa ~~iso> <br />Page t ot 2 ref. Handbook 1378 <br />