Financial- Marion Co. Housing Authority

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. ~ For Ageney Nam,r of Apency: Prqact Nam~ a Nurt+Der Cass Numbar Use OniY~ A~ ~ 1 11 c \_~,.1.~ ~ I~ Claim for Moving and Related Expenses -- Families and individuals Publlc Reporting 8urden for ihis cotiecdon bf infamaCOn is~Gmatedto average0.5 houfs per response, ~~clud~ng the dme torrev+ewing instrvcoons, searching ex~sting data so~~r~s, g~thenng and maintaining the data n ded, and compleung and reviewing Uw collecoon of informauon. Send comments regarding tnis burder, estima~e or any other aspect of this collectan ef infamaGOn, includng sugges6ons for reducing this burden, ro the Reports Management Officer, Oflice of Inlormation Folicies and Systems, U.S. Department ot Nousing and Urban Devebpmen~ Washington, D.C. 20d10-3600 and to tho OHice of Management ar~d Budget, Paperworfe Reduction Project (2506-0016), Washi~gton, O.C. 20503. Do not send this completed form W either of these addresseei. Instructlons: This claim torm is (or the use of tamil'~es and individuals Tpplyin9 tor payment of moving and related expenses. You may appy tor either (1) a fixed allowance, or (2) an amount ta cover the actual moving and related expenses incurted (as described on page 2 ot this lorm). A claim fnr ac'atal expenses must be supported by receipts or other evidence. The Agenq. wi~~ explain the dilterences between the two rypea ot paymenu and will help you complete this form. If the tull amount of your claim is not approved, t~e Agency will provide you with a wrinen explanation of the reason. If you are not sa0sfied with the Agency's determination, you may appeal that determinaoon. The Ageney will explain how to make en appeal. o~e ro _ ~ ~,n,'~ ~___..,~._ < Unit That You i ' Moved To 5. Is This a Finai Claim? ~ i. You~ Name(s) (You a~e me C:a~mant(s)) ~ ta. Vrasent MaiGnp Addrsss(es) ol Claimanqs~ ~b. TNlphona NumDw~s) ~ ~ a ..~,.~ ~.~~-~-! -~ .~v~=~~-- NOn ~, 2 Have All Members o! the Household Moved co the Same Dwelting? Yes ~~ No (If'No.' ~~st the names of all members and the addresses to which they moved in the Rema~ks Sectan.) ---- -- -- ~--'-- -'--- How Many Rooms I Wu p FurrnsMd w~m When p~d You ~,e~. ~9 -_ Oid You Oocu ~' Yow Own furniturs? tibw to Th~s Un~c~ ~ Address (indude Apazvnent No.) PY . i 3 UnitThatYou ------ ~ P`l~ .y~ ~1~ ~~iQ ~Yes ~No I ~,I~~ M d F m'~1 lL ~~ 6. Computation of Payment (coe+oie~e Ircm 6a a 6b) ~ ~ Appendix I i, Il~ndb~x~k 1378 C'll(:-1 U.S. Departmant of Housing ~\ and Urban Developmeni • ~r OMB Approval No. 2506-0016 (Exp. 11/30N2) I ' Eadud~nq Dattxooms, ~ halN+ays and cbs~ts. No i (1) Moving Cost (2) Trans~ortation Cost-Families and Individua~s (3) Cost of Insurance Cove~ing Move andor Storage (4) Storage Cost (Comptate Item 10 on page 2) 6b. Aaud Movina EYOensas I For S S (5) O-her (Explain in Remarks Secdon) ___~!//.U/!!/<G1//.~lLs~:;l!//.~~ ~ ~S S (6) Total Amount of Claim (Cors~It Aqency fo~ amount of Fa~d albwanu) I S C/1 ~~ 1L__ (7) Amount ?reviously Rev:iv8d, it any _ ~ _ ~ (8) Amount Rt~~ested (SuOUact 6nt (~ t:em Ii:w (6)) I S i S S 7.Certil;cation Hy Claimant(s): t cert~y that this daim and supporting intormation are trve and complete and that I have not been paid for these expenses by any other source. I a' that the amount on Gne (8) of ~tem 6 be paid direcdy ro ~me ~ Ihe contractor(s) (as specilied in the Remarks Seaan) ygnatwe(s-o~C~a~m ~{s a~e: X X 1 / ? - • Warning: HU ill prosecute fa e claims and statemenls. Convic6on may rasult in criminal and~orciv7 penalties. (18 U.S.C.1001,1010.1012:91 U.S.C.3i29.3802) I To Be Comple~ed by the Agency Paymen~ Acuo^ A~a:nt ol Paymsm ! S~qr.atu~e ~ ---- ----~ -- - • -•---._ .. _ ... --- -t--°---_..__..__ _.__ i- ~ 8. Recommend~:d ~ S ~ I ~ -- ---- - - • - - -• -- ~ _ . ._ - ~-- _ _.. .. _..----- i --• ~--" I 9. Approved S i ~ ~ Page t o: 2 Name (Tyos or Prnq ~ Da~e _ ~ I ~ - _ i lorm HUD-00054 (tlS2) ref Handbook 137A