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Cla9m for Moving and Rel ed Expenses u.s. ~nm~ o~ -~«,~,~ ~~ <br />Families and Individuals and Urban De+relopmer» ,~ <br />OMB Approval No. 2506-0016 (exp. 1 t/30l90) <br />For Agency Use Only ~ <br />Name ot Apency Pra~ect Name or Numpe~ Case Number <br />PuDlic roportinq Cu~tlsn for t~ia eollxtioMO~ information ia eaumataq to averape 0.5 houra per rosponae, incluClnp the time tor roviswinp instruction~, aearcmny ex~stinp aata aourees. <br />pst~aAnq and maintainfnp th~ Oafa needM, an0 completinp and nJ~/winp th~ eollectfon of Informadon. Ssntl commsnta rparOlnp tnla burCen eetimate or any otner aapect of Inis <br />c~119CClon of Mfortnetlon, Includinq luppsatlone for rlOUCinq Inis burden, to tne RepOrts Min~pement Ottlcer, OHice of Inlormalion Pollcisa sntl Syllema, U.S. Dspanment of Houaing <br />an0 Urban Devslopment, WraMnQton, O.C. 20/143800 anC to tns 011ics of Mansqement entl 8u0pet, Paparwork HeOuctlon Pro~sct (2506-0018). Wunlnpton. O.C. 20503. <br />Prfncy Ad Notic~c This Infortnation is needed to determine whether you are ellgible to reCeive a payment for moving and related expenses. You are not required <br />~y law to fumish thls Infortnation, but if you do not prrvide it, you rt~ay not receive any payment tor these expenses or it may take longer to pay you. This <br />infornatlon is bel~p collected under the authority of the Unitortn Relocatfon Assfstance and Real Property Acquisitlon Policies Act of 1970. The infortnation may <br />be made avallable to a Federal agency for review. <br />Inswetbnc Thls clalm form is for the use of famllies and f~dlvitluals appiying for payment of moving anG related expenses. You may apply for either (t) a fixed <br />allowance, or (~ an amount to cover the actual movinq and related expenses incuned (as descrlbed on pape 2 of this fortn). A claim for actual expenses must be <br />supported by reCeipts or other evidenCe. The Aqency wiil explain the differences between the two types of payments and will help you Complete t~is form. If the <br />!ull amount of your clalm is not approved, the Apency wlil provide you with a wMtten explanatlon of the reason. It you are ~ot satisfied with the Agencys <br />detertnlnatlon, you may appeal that detertnination. The Apency wlll explai~ how to make an appeal. <br />t. Your Nema~sl(YOU are the Cltlmant{sp 1a. Proesm Mallinp AOdrosa(ss) of Claimanrya) ~~^c 1b. Telsphons NumDeqs) <br />o1o~C; ~ ~gh ~- • ~G ~~~ <br />SO~ ~o (~ ~,-c_.\~ . ~ca 1-e,m c,'R ct~3o1 <br />2. Have All Members of the Househotd Moved to the Same Dwelling? ~ Yes ^ No <br />(Ii "No", Iist the names of all members and the addresses to which they moved in the Remarks Section.) <br /> MOw Many Was It FurnUhaC• When Di0 YOu <br />Dwlllln9 ACd~ea! ~1nClutl! Apartmont NO.) ROOm! Ditl Wlth YOU~ Own MOV4 To <br /> You OteuDy~ ~ Fumiture? This Unit? <br /> <br />3 <br />T ~Q ~ 11~~ ~ <br />. Unit <br />hat You <br />Moved From ~ <br />~~,~ ~~ C~~3V ~ <br />~~10 ~ Yes ^ No <br />~v~ ~--~~~ <br />4. Unit That You ~Exeludinp Dat~rpoms, <br />Moved To nauwaya ana e~ossts. <br />5. Is This a Final Claim? [ SQ Yes ^ No (If "No", Explain in Remarks Section) <br />8. Computstbn oi Payment (Complete Item 6a or 6b) <br />Item 6a Fixed A~lowance 6b. Actual Moving <br />Expenses Fw Agsney Use Only <br />(1) Movinp Cost S S <br />(2) Transportation Cost - Families and Individuals <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 ~ca,sw~ ~9e~cv for amoum oi rxed ~~owa~,ce~ S a O~ u~ S 3 <br />(~ Amount Previously Received (If any) <br />(8) Amount Requested (Subtract Line (7) from Line (6)) S S S <br />7. Certificatbn By ClaimaM(s) <br />Warninq: M you krwwinply maks false statsmsnts on thla form, you may be subJect to civil or criminal psnakfes undsr Section 1001 0( Title 18 of the <br />Unksd SUtas Code. In sddition you may not rseaivs any of the emoums clalmsd on thl~ form. <br />I Csrtlty that this claim and supporting information are true and compl and that i have not been paid for these expenses by any other <br />source. i ask that the amount on Line (8) of Item 6 be paid directly to ~ me ^ the contractor(s) (as specified in the Remarks Section). <br />Sipnature~al ol Cirimant(s) Date <br />~ ~i~ j ~~.Lc~: ~-~~,~ ~ ~ _ ~ -~ ~ <br />To Be Com tsd By Agsncy <br />Payment c on Amount ot Payment S~gnature Name (Type or Print) Date <br />8. Recommended S <br />9. ApprOVed S <br />Page 1 of 2 fortn HUD-40054 (1/90) <br />ref. Handbook 1378 <br />