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05,+28!199? l~: ~5 50~-297-28~5 H~NN~ h~iCELDOi,JNE'r P~~GE 06 <br />Oregon Departmenr of Trar~sportation <br />RELOCATION <br />REESTABLISHMENT CLAIM <br />osr To: <br />Mar Po Federal Credit Union <br />~daillnq AaOr~sl~ <br />Cl~lrnan~'~ N.ntie <br />Jim Ebezle, CEO <br />Fa. No <br />Sect~o~ <br />Mi9Hw~y <br />I <br />County <br />FAP No ~ <br />I clzim ttle follow,;ng costs incurred in relocafln8 and reestablishing my smatl <br />bu~inesa, fa~m or non-profit orgsnlzatlon. t h$ve attached actuai recelpts to <br />verify my expenses, a~d i flave included written support for all estlmates. My <br />claim is based on the follov++i~g; <br />Repairs or improvements required by law, code, or ardinance. <br />Modiflcatlons tv accomodate tt~e buslness ope~ation. <br />Constructlon and installation costs for exterior signing <br />Provision of utilities From ~ight of way to improvements <br />Redecoratifln or replacement flf sailed or worn surfaces <br />~icenses, fees and parmits not paid as pa~t of moving expenses <br />Feasibility surveys, soi! testing and rnarketing surveys <br />Advertisement af replacement locatifln <br />Professionai services in connection with the purchase o~ lease of a <br />r8plac8ment site. On Form 203 <br />Estim~ted increased costs oF operatio~ during the first 2 years at <br />the replacement site for such items as : <br />A. ~ease or rental charges <br />~8. Personal or Real Property Taxes <br />C. Insurance Premiums <br />D. Utility Charges, excluding impact fees <br />fmpact Fee or one-tlme assessments for anticpated heavy utility <br />usage <br />Other {explain) ~ ~d^~ ~ G`0°' ~`~ 4• <br />Total (fei~xse~e~-~E~c~E-Eo-e~ve~~~6~38g) <br />~~ ~~ ~ <br />~l~ <br />f w~ a~; <br />~ <br />~~ <br />~ ~ <br />3 i6 ; #~1~6Q"-'r~ L~oS~ • b~ <br />$ 977.~0 <br />$ <br />$ <br />$ <br />$ ~ <br />$ <br />$ <br />$ <br />7.213.44 <br />$ 9.104.8$ <br />$ - - <br />$ t~ unn nn <br />$ <br />$ <br />$ ~a-r~2~- ( 0, O 0 a <br />_~I.~~ <br />$ (O, ~04 , 4~j ~. A • _ <br />Agent's Signsture <br />IZevlpwdr'7 $i~nSSUr~ <br />Form 205 (1 1195) <br />Oaie <br />Oate <br />RELOCATION <br />REESTABLISHMENT CLAiM <br />