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Claim for Moving and Rel~ated Expenses U.S. Depertmerri of ~ <br />and U-ban Development <br />~ <br />~~ <br />Families and Individuals OMB Approval No. 250~0016 (exp „no~o <br />For Agency Use Only _ - <br />Name of AOe^cY Pro~ecl Name or NumDer Caee Numper <br />\ 1 ~ ~ ~1 "-i , • r i l~ 5 p , (/~ ~ c~- ~ I <br />~ ~ ~l,l~t ~`U i ~~_~ _~~iVt~cY i1:i~ -, <br />1~ i~1. ~~ O~l ~~ ~~v~l ~~~ ~~C~l.~i I`Y~ 1~(.X_- ~ <br />~ 1 f ~ ;.. • <br />PuDirc roDOrtinp puroen Ior mia couection oi inlortnaUon ia esumatsG to averape 0.5 nours pa~ reaponee. ~ncwofn0 tne tims tor rov~aw~np inatr~ctions, ~earcnina eYie~mp eata sources. <br />psmennp ~nC malntalnin0 tna Gata neeaso. anC completinp and nv~~winp tns couectlon ol Inlo~ma~ion. Sentl commsnta rsparoinp t~ie bur0en eadmafa or any ot~er a0ett ol t~is <br />co~iection ot intormetion. inciud~np euppestiona ~o~ reEucinp thle DurOen, lo the Raporte Manapement O~~~cer. OHice o~ Infortnat~on Poiicies antl Syatems, U.S. Oepanmeni oi r+ous~~9 <br />ana Uroan OsveloDment, Wuhington, O.C. 20ai0-7600 snd to tne O~~~ca of Mansqemem u+0 BuCpat. PsOenvork Hsduction Pro~ect (2506~016~, waahinpton, D.C. 20503 <br />Pri»ey Aa Na{c~: This Intortnation is needed to detertnine whether you are elipible to receive a payment tor moving and ~elated expenses. YOU are nol requ~retl <br />by Iaw to furnish this information, Out if you do not pro~ide it, you may not receive any payment for these expenses or it may take longer to pay you. Th~s <br />intortnatlon is belnp collected under the aulhority of the Unfform Relocatfon Assistance and Real PropeRy ACCul~itlOn Policies Act of 1970. T~e infortnatlon may <br />be made available to a Federal agency for review. <br />Inswabnc This claim fortn Is lor the use of families and individuals applyinp for payment ol moving and relateG expenses. You may apply for either (1) a fixed <br />allowance, or (2) an amount to cover the aCtual movinq and re~ateC expenses incurted (as dascriDed on paga 2 of this fortn). A clalm for actual expenses mus- be <br />suDOOrted Dy receipta or othe~ evidence. The Apency will ezplain the ditferences between the two types o( payments and will help you comD~ete this torm. it the <br />full amount of your claim I5 not apD~~ved, lhe Apency wlll provide you with a wrltten explanation of the reason. If you are nol satlsfied with the Agency s <br />detertnination, you may appeal that detertnination. The Aqency witl explain now to make an appeal. <br />t. Yo~r liame(s) (~'ui ue Ihe Claimant(sl) ta. Prssent Msilinp AGCresales) ol Claimanqsl 1D. TeleO~~e NumDer(s) <br />~~~~~~~~~. (~1 ~~a~~s~.n <br />JL' nC~~ Q'~[1('Eme^~t ~~.-1 I <br />~~g 1\;5,.1~ 5~_ (~:c , , <br />~j ~ i~n~ <br />2. Have All Members of the Household Moved to the Same Dwelling? .~ Yes ^ No <br />.. .._. .. .. _. .~ _ _____ _. _~~ ...,....~.,.~ .,..a •~e ~.~.~.oQ~o~ rn wnich thev moved in the Remarks Section.) <br />(11 -~ryp ~ n5l lnC ~~a~nca vi u - ----- -- - <br />Mow Many <br />Wri It Fumb~eG• - <br />W~sn Oid You <br />~„e~~~~fl ACdfaS311ntlud! ADarlm~nt NO.) Aooms Di0 <br />You OccuDY~ ~ Wlt~ VOUr Own <br />Fumiture? Muve To <br />Tnis Unit? <br /> ~~~}O` ~ Q}5• ~ <br />~ ~ <br />~ ~u"d~0 ~ Yes ^ No ~~ ~~'~ <br />3. Unit That You - <br />`~~~ ~~4~-h S~. ~C <br />Moved From <br />` ~.~ 301 , <br />4. Unit 7hat You 'E=dua+no eatn~oome, <br />Moved To na~iwars ano c~oxts. <br />5. Is This a Final Claim~ (~ Yes ^ No (If "No" Explain in Remarks Section) <br />ir.......~e~n I~nr~. R~ nr Rh1 <br />0. I.OfI7PURi1W7 v~ ra)nwu~ ~wn.N~vav ....... ....... ~~~ <br /> <br />Item <br />6a. Fixed Allowance <br />6b. Actual Moving <br />Expenses <br />For Aqe~cy Use Only <br />(1) Moving Cost S a <br />(2) TranspoRation Cost - Families and Individuals <br />(3) Cost of Insurance Covering Move and/or Storage <br />(4) Storape Cost (Complete Item 10 on page 2) <br />(5) Other (Explain in Remarks Section) <br />(6) Total Amount o( Claim ~co~ew~ ~oencY r« a~++oum oi r:eo a~ioWance~ S~t- O~~~ ~~ $ $ <br />(~ Amount Previously fieceived (If any) <br />(8) Amount Requested (Subtract Line (~ from Line (6)) s s $ <br />7. CsrtlNcatlon By Clalmant(s) <br />Wernlny: II you knowingly maks false statsmsMS on lhls torm, you may be subiect to civil or eriminal psnaltias under Sectbn 1001 ot Titls 18 of the <br />Unk~d Statas Code. In aCdltlon you msy not rscslvs ~ny of ths amounts elalmed on thls form. <br />I Cenly that this claim and supporting infortnation are true and complete and that i have not been paid tor ihese expenses by any other <br />source. I ask that the amoYnt on l.ine (8) of Item 6 be paid directly to ^ me ^ the contractorls) (as specified in the Remarks Sectionl. <br />Siqnature~sl 01 <br />~ <br />~ ~ ~~ l <br />~; ~~ i~~', ~~~~-z ~ <br />T Be CompleteG By Agency ' <br />Payment Action ~ Amount o~ Payme~~__ <br />B Recomme~dedl 1 <br />-------- --- - <br />9 Approvetl I i <br />oa~e <br />Name (TyDe o~ Pnnt) I Date <br />Signalure -- --- j _.. <br />--- ------~ _. <br />--------+ . <br />I <br />Page t ol 2 <br />fortn HUO-40054 (t/90~ <br />ret Handbook !37~ <br />