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~ <br />~laim for Moving and Related Expenses <br />Families and Individuals <br />~ <br />Name of Ap~ncy 'Pro~sct Nvn~ or Numbsr ICas~ Number <br />~ ~,~'~ 1(_ C \ ~ _~~:t~'a~ ~ ~-~<L~\~~~!~ ~ ~ X`~"~~cCXt ~ ~3~ ~~ <br />P~Diic rsport~nq Durtlsn tor th~s coiiection ot ~tom+atfon ia sstlmatWto eraqe 0.5 noun par roapons~, inc~udinq t~~ tlms lor rsviewinp ~nstrucuons, searohinp existinq aata aources. <br />qsthsnnp ~n0 mdntalnlnp tM data nseGed, anG compl~tlny and revls ths coll~ctlon o1 infortnatlon. S~nd comment~ npar0lnp thls Durtlsn ~stlm~te or any othsr aspect o1 this <br />co~ix~ion or intom+ation, includinQ suppeations for retlucinq tAis Durd~n, t0 th~ RepoAS Man~pNn~nt Oftlc~r, Otfles of Infortnatlon Polleiss and Systsms, U.S. Dspartmsnt o~ Mouain9 <br />an0 UrD~n O~vsloDm~nt, Wuhington. D.C. 2W t43800 an0 ta tM Ottfc~ of Man~psmsnt and BudpN. P~psrwork ReOuctlon Pro-set (2506-0018), Washinpton. O.C. 20503. <br />Prtacy Aa Nak~ This Information is needed to detsrtnlne whether you are eliylble to receive a paymsnt for movinp and related expenses. You ere not required <br />by law to fumiah tAis Infortnation, but if you do not provlds It, you may not receive any payment for theaa sxpenses or it may take longer to pay you. This <br />intortnatlon Is beln0 collected under the authoMty ot ths U~Iform Relxatlon Aasfstancs and Rsal Propsrty Acqufaitlon Polleles Act of 1970. The fnformation may <br />be made avafiable to a federal aflency for review. <br />Inwvetbnc This claim fortn is for the uae of famflies and IndfvlGuals applyfny for payment of moviny and rolated expenses. You may apply tor either (1) a fixed <br />ailowance, or (2) an emount to cover the ac:ual movlnq and -elated expenses IncuRed (aa described on paqs 2 of thls fortn-. A clafm for actual expenses must be <br />supported by recelpts or ot~er evidence. The Apency will szplafn the differencea betwee~ the two typea of payments and wlll help you complete this form. if t~e <br />full amount ol your claim fs not app~oved, the Aqency will provide you with a wrltten explanatlon ot the roason. If you are not satisfied with the Apency's <br />detertnination, you may appeal that determinatfon. The Apency will explafn how to make an appeal. <br />t Your NamNal (YOU an t~e Clafman11s1) ta Prssont Mdlinp AdErsss(es1 of Gtafm~nqs) ~b. istepnon~ numosri~) <br />:~ ~ C.~ H~~1 ~v~r ~. ~ ~ ~ C' <br />1 "` ~ ~1 1`)r' ` V~j`~~'a 1 1'iC? '~~ f =1~~~'1~ .~.-U~ `~_ ~~ ~ ~~ ~ ( !`~ ', ~1 J r ` 1, ~ C~ <br />2. Have Att Members of the Household Moved to the Same Dwelling? (~Yes ^ No ~ <br />nf •~N~~~ i~sc tne names of ali members and the addresses to which they moved in the RemaAcs Section.) <br /> How Many Was It Fumishs0• Wnsn Di0 You <br />Dwsllinp AddffSa (Inelude ADartment No.) ROOms Did <br />You Oceupy?~ Wlth YOU~ Own <br />Fumiture? Move TO <br />Tnie U~+t? <br /> ~~ ~. ~ '~~~Y ~ ~- ~.~ ~ ~j\~\ <br />3. Unit That You ~~ ,J ~ Yes ^ No <br />Moved From ~C,`~ o~( 'C~ C~x'~ C'l ~} ~~ ~+ 1 V-~- G~ <br />4. Unit That You ~Exeludlnybatnroqma. <br />MOVed To nanways ana elos~ts. <br />5. Is This a Final Claim? ~ Yes ^ No (If "No", Explain in Remarks Section) <br />6 Computation of Paymsnt (Complete Item 6a or 6b) <br /> <br />Item 6a. Fixed Allowance 8b. Actual Moving <br />~pe~SeS <br />For Apsncy Uae Only <br />(~) Moving Cost S S <br />(2) Transportation Cost - Families and Individuals <br />(3) Cost of Insurance Covering Move and/or Storage <br />(a) Storage Cost (Complete Item 10 on page 2) <br />(5) Other (Explain in Remarks Section) <br />(6) Total Amount of Claim tc«+sun ~a«+ey ror .mouni o+ rirw a~~aneel S a` ~,(~~ s $ <br />(~ Amount Previously Received (If any) <br />(8) Amount fie0uested (Subtract Line (~ from Une (6)) S S a <br />7. Csttifkatloe 8y Clalmarn(s) <br />Wsrninq: it po~ knawinyly maks tals~ stat~msrtts on this fom~, you may b~ wt~~ct to eivil a criminat p~nakf~s under Sectlon 1001 ot Titls 18 ot ths <br />Unit,rd Stat~s Cods. In addition you may not neNv~ any of th~ amounts elalm~d on thls fam. <br />I Csrtlty that ttxis claim and supporting infortnation are true and complete and that I have not been paid for these expenses by any other <br />source. I ask c*tat the amount on Line (8) of Item 6 be paid directly to ~ me ^ the contractoqs) (as specified in the Remarks Section). <br />Sipna~ure~e~ of Oartnancla) <br />~ /// LS%v~l' <br />Tn ti. Cnmal~d 8v <br />Payment Act~+~+ , Amount of Payment Signature Name (Type or Print) Date <br />8. RecommenCx~~ S <br />9. Approved S <br />~ ~~~ <br />U.S. Departm~rtt ol Housirq ~ ~ <br />and Urban D~vNo(xnsnt <br />OMB Approval No. 2506-0016 (exp. 1 t/30/90) <br />Page t of 2 iorm HUD-40054 (1/90) <br />ref. Handbook 1378 <br />