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« <br />~ : ~. <br />Y ~~ <br />Oregon Deparfinent of Transportation <br />Pay To: <br />vr~~~...~..e. .~~"y~/- ~ <br />Mailing Address , <br />- Z~ 1 fi.,,t S = <br />~~ ~~ ~ I <br />Ciaimant's Name ~ <br />~M ~ ~.l_ <br />.nh~ <br />~ <br />,~--~ <br />RELOCATION <br />FIXED PAYMENT CLAIM <br />/o, <br />~ l-~~~ . <br />~. ~V~t c~,.~,e.1 ~. sc.L.z..1._ , Proprietor of _~ ~.¢~, t,.s, ~.\e~,:.s t1 i,.~e_ located at <br />55~, C.o,,,ra- S~. rJc hereby make application for Fixed Payment in lieu of moving expenses as <br />a displaced ~ business, Q farm, p non-profit organization (NPO). - <br />! understand that to be eligible for the fixed payment, f cannot be relocated without a substantial loss of <br />existing patronage; and further to be eligible, I must not be a part of a commercial enterprise having more <br />than three other entities which are not being acquired by the State, and which are under the same <br />ownership and engaged in the same or similar business activities. <br />i undertand that the fixed payment is to be based on one-half the "annuai net earnings" before Federal, <br />State, and local income taxes during the two taxable years immediately preceding the tax year of <br />displacement, not less than ~1,000 nor more than ~20,000. <br />I understand that the amount of payment I ~eceive will be computed from the Oregori Income tax returns <br />filed by myself, copies of which are attached. <br />I understand that the fixed payment is in lieu of all other relocation benefits and that the premises must be <br />vacated and teft clean arrd orderly. <br />I certify that I am the p~oprietor and have operated the business, fa~m, or NPO for ~y months and that <br />the statements contained herein are true and cor~ect to the best of my knowledge and belief. Based on 1.~ <br />the above, I claim a fixed payment of $ Zo v~o ~ . Sec ~ s~.r-~..•~r-~J~-~~ Z-111 ~~'~ - <br />;~,~~/-~,~G ~ - ~~ - ~ ~ - - _ <br />~ P~~~~~~ Oate App~icant ~ Oate <br />The subject property was inspected on an~1-€~und to be vacant, clean, and o~derfy. An <br />inspection of the proprietors Oregon Income Tax returns indicates that the proprietor should receive <br />payment. I recommend that the proprietor be paid the sum of $ - <br />~ - E. n. . <br />Form 204 (11/95) <br />Oate <br />Oate <br />RELOCpTION <br />FIXED PAYMENT APPLICATION <br />Pa 3 of 2 ges <br />~~ 3-t~- <br />ppr I~ <br />AgenCS Signaturc <br />Reviewe~s Sg~ature <br />