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~" <br />Claim for Moving and Related Expenses <br />Families and Individuals <br />For Agency Use <br />~ ~ <br />U.S. Dspenmsrtt of Housing ~ ~ <br />and Urban ~eveto~xnsnt <br />OMB Approval No. 2506-0016 (exp. 11/30/90) <br />Name of Ape~cy <br />~`rl Q rion Co~n~ <br />Pro~eet Name or Number ~Case Number <br />~e~~.~ A~Q~~~~~` ~,~~b <br />ruoac ropornnp Durden for tnls conection ot Infortnation ie satimatsd to avsnqe 0.5 nouro per roaponas, Inclu0lnp the time for raviewinp inetructlona, aearchinp exi~tinp data sources, <br />pathaAnp ~nC mdntunlnp tM deta nsstled, and comptetinp and rMwvlnp tM colbctlon of Informatlon. Send eomments rpWinp thla Durden satimats or any other upset ol this <br />colisctlon ot Informatlon, includlnp suppeationa 1or rsOucinp this burdsn, to tM RspoAS Manayement Ofticer, O(fics of Informatlon Policisa an0 Systsms, U.S. Department of Mouainp <br />~nd Urban pevelopmsnt, Was~inpto~, D.C. 20410~380p ~nd to t~s Offie~ of M~n msnt and Budpet, Papsnvottc Reductlon ProJsct (2508-001g), Waa~inyton, D.C. 20503. <br />P„r+~Y ~~ Not1eK Thia lnfortnatlon Is needed to detertnine whether you are eligible to recelve a payment for moving and related ezpenses. You are not required <br />by iaw to fumish this Information, bul if you do not provide it, you may not receive any payment for these expenses or it may take longer to pay you. This <br />infortnatlon is beinp collected under the authority of the Unifortn Reiocatlon Assiatance and Real Property Acqulsitlon Polfcles Act of 1970. The Information may <br />be made available to a Federal agency for review. <br />inaruetbnc This Clalm fortn Is for the uae ol famllies and individuala applyfny for payment of rtaving and rslated expenses. You may apply (or either (1) a fixed <br />allowance, or (2) an amount to cover the actual movinfl and related expenaes incurred (as deacribed on pape 2 0( this fortn). A clalm for aCtual expenses must be <br />supported by recelpta or other evidence. The Agency will explain the differences between the two types of paymenta and will help you complete this form. tf the <br />full emount of your claim is not approved, the Agency will provide you wlth a written explanatior. of the reason. If you are not satisfled wfth the Agency's <br />determinatlon, you may appeal that detertnination. The Apency w111 explain how to make an appeal. <br />~. Your Name(a-(You ae the Galmant(s)) 1a Prossnt Mdlinp Addnsa(ss) of Galmant(a) lb. TsISD~+one Number(s) <br />~~on0.~c~ ~. , ~Uf1~S Se.na~ ~ <br />- - ~~ ~ ~u~ h~'N~ Nc~ne- <br />2. Have All Members of the Household Moved to the Same Dweiling? ^ Yes ^ No <br />(If "No", list the names of all members and the addresses to which thev moved ~n tnQ ap~.,A.tie c~~~.,., , <br /> <br /> <br />~e~~~^0 - - <br /> <br />Adtlresa (Ineluds Apartmsnt No.) --- -- ------- ----._ <br />How Many <br />Rooms DiC <br />You peeuDY?~ ..., <br />Was It FumisAed• <br />With Your Own <br />Fumiture? <br />When Did You <br />Move To <br />Thia Unit? <br /> <br />3. Unit That You <br />MovedFrom Se.~: • <br />~~g Wj PS-}. N~ <br />~ <br />r <br />~~ ~ <br /> <br />~Yes ^ No <br />3 <br />9 I <br />C~ <br />g <br /> ~~~ <br />0~ Q <br />~~) I - <br />_ <br />4. Ufllt ThBt YOU 'F~cclu0lnp bathrooms <br /> <br />MoVed TO , <br /> <br />~ n~~waya anC Uossta. <br />~. ~a ~rna a r~nai ~,ia~m~,~ ~@S I,J NO QT "NO" Explafn in Remarks SeCtion) <br />B• Computatlon of Paym~nt (Complete Item 6a or 6b) • <br />Item 6a. Fixed Allowance 6b. Actual Moving <br />Expenses <br />For Agsncy Uss Only <br />(1) Moving Cost s a <br />(~ Transportation Cost - Families and Indfviduals <br />(3) Cost of Insurance Covering Move and/or 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~a~u n~~cy rw ~o„~~ or nxso rwwance) S ~ 0~ <br />~ S $ <br />(n Amount Previously Received (If any) <br />(8) Amount Requested (Subtract Line (~ from Line (6)) <br />~ ~_..,.~__.~__ e.....-~---~-~ S s g <br />~..,.., ..~ .. <br />Warniny: N you knowinply maks falss statements on this form, you may be subject to civil a c~iminal psnakies under Sectbn 1001 of Title 18 of the <br />Unk~d States Cods. In addition you may not recNr~ any of tFa amouMs clalmsd on this form. <br />I Certify that this claim and supporting information are true and complete and that I have not been pafd for these expenses by any other <br />source. 1 ask ihat the amount on Line (8) of item 6 be paid directly to ^ me n the contractortsllas s~ecifiad ~n fnP Rwmarkc Swr.tinnl <br />Payment Actfon Amount of Payment Signature Neme (fype or Print) Dete <br />8. Recommended S <br />9. Approved a <br />Page t ot2 form HUD-40054 (1/gp) <br />ref. Handbook 1378 <br />