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~. ~ ~~~~ -~-, <br />. ~ <br />Oregon Department of Trans orfation <br />~~~~~,~ FIXED PAYMENT <br />Nam-e o~-t {Oisplacea Organi tlon <br />\ ~C..~ln ~ 1 ~ ` <br />Mading Atltlress - <br />3 \ S~Z ~ - <br />~~ ~ ~ JZ. <br />Ovn,er ~ ~ ~ /_ ~ <br />YY~~ ~~. a. ~f <br />Teiephone fJUmber <br />.~ l- ~i 3`-t ~eb. 3 ~ ~- CJ ~- <br />~Business ^ Farm . ~ Non-Profit <br />~~O~j' <br />t <br />Fi~e No <br />!oS'oo~ <br />; ~9~p <br />RELOCATION <br />APPLICATION <br />Name . <br />s~b~ <br />Hignway - <br />COVOty <br />FAP No. ~ <br />1 hereby apply for the ffixed payment in lieu of reimbursement for ail other moving and related costs and <br />expenses. i certify thzt: _ <br />~ I am the owner of the above business, farm operation, or non-profit organization and that this business, <br />farm, or non-profit organization is lawfully located on the re~i property from which my personal property <br />will be required to be moved. This business , farm, or non-pfofit organization has been in continuous <br />operation since 15y'1 <br />BUSINESS _ <br />~This business cannot be relocated without a substantial loss of its existing patronage. <br />~ This business is not part of a commerciaf enterprise having more than three other entities which are not <br />being acquired by the angency, and which are under the same ownership and engaged in the same or <br />similar business activities. <br />~This.business had annual gross receipts of at least $5,000 or had average annual earnings of at least <br />51,000; or contributed at least one third of the operator's average annual net income from all sources, <br />during the two taxable years prior to displacement. <br />~The business is not nperated at a displacement dwelling-0r site solely for the purpose of renting such <br />dwelling or site to others. - <br />FARM OPERATION <br />, <br />p The acquisition of the land or part of the land resulted in the displacement of the farm operation, or <br />^ The acquisition caused a substantial change in the nature of the farm operation. <br />NON-PROFIT ORGANIZATION <br />^ The organization cannot be relocated without a substantial Ioss of existing patronage (membership or <br />clientele). - ~ ~ <br />, _..._..... _. ...~ <br />" 1_ ~~~ ~n_t; ~;ilf/L- ~~ /~~_ d. - ~i - 9 ~ <br />To the best of my knowledge, tt'tts applicant meets the critefia necessary to qualify forthe fixed payment. <br />1 ~ 1 <br />g o y en a e ~ <br />Form 204 (11/95) <br />RELOCATtON <br />FIXED PAYMENT A~PPLICATION <br />Page 1 of 2 pages <br />