Financial- Marion Co. Housing Authority

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. ', ~ Claim for Moving and Related Expenses -- Families and Individuals Appendix I l, Ilandbc>ok 1378 CII(;_- (` `1 ~, ~ U.S. Department ot Housing and Urban Development For Aganey Name ol Ase~+cy" Uss Oniy: ~ \ _ Moved From :~~ Q~ _ _ ~v ~ S~ ~ ' <. Unit That You ~ I ' Eichidv+q baWOOms, Moved To ~ namrays and casw. 5. Is This a Final Claim? ^ es ` No Prqxt Nam~ a NumDer ^ ~r OMB Approval No. 2506-0016 (Exp. t ti30i92 Cas~ N~mDer; " '{ T • 7 ~.1~ ~~ PublleReportingBurdentorthiscoliecuonofinf aGOnisesDm tedtoaverege0.5hoursperresponse,~ncludingtheomelorreviewinginstrvcaons.search~nc e:isting dala sovrces, gathanng and maintairn~g the data needed, and completing and reviewing the cotlecoon of inlormaGOn. Send comments regarding th~s burden estimate or any other aspect ol this colteaion of inlormadon, includng suggesoons lor reducing this burden, to the Reports Management Otficer. 011~ce ol Inlormation Policies an~ Systems. U.S. Department of Housing and Urban Oevelopmen~ Washington. D.C. 20410-3600 and W tfio OHice ol Managemen a~~d Budget, Paperworfc Reducuon Project (2506-0016), Washington, D.C. 20503. ~o not send this completed form to either of theze addressees. In:tructfons: This claim form is la the use of families and individuals applying for payment of moving and re!ated e:penses. You may apply lor either (1) a fixec allowance, or (2) a~ amou~t to cover the actual moving and related expenses incuned (as desc~bed on paye 2 of this twm). A claim foa actual expenses mus be supported by receipts or other evidence. The Agenry will explain the diHerences between Ihe Nvo typef oi payme~ts and will help you complete this form If the Iull amount ol your claim is not approved, the Agency will provide you with a written e:planatan of the reason. If you are not saosfied with the Agency~ determinacon, you may appeal that determina6on. The Aqency wiU explain how to make an appeal. t. Your Name(s) (YOU a~a v+e G:aNnane(sp ~ ~a. Prasent I~la~linq Addres`s^es) 1 Gairt+anqs) ~~~ • lb. TN~pl+ona NumDa(s) ~ c !2!~" ' ~ r , ~ . 2 Have Atl Members o: ~t+e Household Moved to the Same Dwelling? es No _ ~-f (If 'No.' list the names of all members and the addresses to which they moved in the Remarks Sectan.) ~~~ ~~ `~ ---- ~-.~-- ---- -~ How Many Hoorns I Was It FurrtisMd vnQ~ I WMn Ud You pn„alSr.q ' AdOress (induds Apartm~nt No.) O~d You Occvpp? ' ~ Your Avn Furrwan? 1 Mow ro Tnis UMt? 3. Unit That You~ ~~la~~~~~ ---~ ' L,Yes ~No h- L.J 6. Computatlon ot Payment (cor+aie~e Item Ba a 6b1 ncm (t) Moving Cost ~ . ~ - --- -' (2) Transaorta6on Cost-Families and InCivid~als E (3) Cost ol Insurance Cove~ing Mova and~w Storage (a) Stora~e Cost (Comp~te Item t0 on page 2) (5) Other (Explain in Remarks Sac6on) S IS (6) Total Amount ol C:aim ~CorsJt Agency I~r amount ot fixed albwanca) ~ S ~~(l~ ~~ ~ S I S (7) Amount ?reviously Rec~ivad, it any (8) Amount Rc.~es~ed ~S.ovac. w+e ~~~ r:u*s i~ne (et- ~ S i S ( S 7.Certificatlon Hy Claimant(s): I certi.y that tl~is daim and supporting inlormatan are ave and complete and that 1 have not been paid lor these expenses C an~ other source. I asR that the ar.+ount on Gne (8y of Item 6 be paid d~rectly to ~me (~ the contracar(s) (as specitied in It+e Remarks Sect'an) 5~naw~e(s) d Ga.~at+c(s) b Oate X War : H wl rosecute false claims and staiements. Convic6on may r~sult in uiminal and/or c'rvd penalties. (18 U.S.C. 1001.10~0,1012:91 U.S.C. ~%29. ]8~ To Be Compleled by tho Agency Payment Acua^ a~~;ni ol Pay^+e~~ ~ S~qna~u~e ' Name (Tyx or Print) I_ Date - - -- ---- - - • - ~ - - ••---'1--' --~- -•--... .. _ . ._. . . _._ , I I 8 Recommendt~d ' S , ~ i . , ~ ~ - --- _ . ~. _ "'... _ .... _' '_ . ""'___ I ' _" '_'_""'__'"_____.~T_ 9 Approved -- - • S - - I ' ~ ! j I ~ . ~ Page t o: 2 form HUD-4005d (v5 rcf Handbooktl