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<br />Oregon Department of Transportation
<br />Pay To: ~~ ~/R n~ M LGy~ ~~ R rr~
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<br />Mailing Address
<br />C~ ~i 8 12 ~ S'-E . s'. E• 5~.,~ ~` 2~ a
<br />S'~:~,~. , bR ~r -~ 30 ~
<br />Ctaimant'S Name
<br />q.~._~ ar, a. 6 o re
<br />I am applying for payment incurred in searchi~g for a replacement site.
<br />RELOCATION
<br />S1TE SEARCH CLAIM
<br />fik No.
<br />Name
<br />5~~,
<br />Hiqhway
<br />County
<br />FAP No
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<br />~~~
<br />' 2 5 ~i1~9~
<br />;~~,~, ~-,~; %`~~.~ y
<br />I understand that I may be reimbursed for the acutal reasonable expense in searching for a rep~Gc,ement site, not to
<br />exceed $1,000. Such expenses n~av include cosis of transportation, meals, lodging away from home, and the reaso~~ahie
<br />value of time actualfy spent in the search, including the fees of real estate agents or real estate brokers.
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<br />All expenses claiined, except ~ialue of Fhe iime actually spent in the search, must be supported by receipted bills. Pdyme~.~
<br />for miles driven ma~~ not exceed 20 cents per mile.
<br />Payment for the tirne actually spent.in the search shall be Lased on the applicable hourly wage rate for the person(s)
<br />conducting !he search but may not excead $30 per hour.
<br />DATE
<br />j
<br />j MIIES DRIVEN RA ~E ?FR
<br />P,AIL~ DAILY
<br />CHARGE HOURS SPENT RATE OF PAY DAILY'
<br />CHAr'1GE MEA!_S &
<br />LJDGING
<br />~
<br />0 1-~1 ~
<br />~, _
<br />~ -
<br />. 26 _,~~, ~
<br />-- ~ ' 3~. °D li
<br />a ~+ ,~ ~~ ~ 0 _ °-~e-
<br />2 f o , r'° __ ~
<br />-
<br />_
<br />~i 4
<br />
<br />~ 2 a 4 _
<br />~0 i
<br />~
<br />I O
<br />:3 0 _ 20 ~.~
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<br />
<br />~ 30. ,,
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<br />~ ~I ~_~4~
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<br />2/O j, ~ 1 ~ I~' . 2D 60' O y 6b _`~`' ;
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<br />a °C 7 ~ 20 -_ ~ -2a _-.~ _ °° (~ 0. ~~ ~,p_~'° - ~
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<br />Subt~tal of Vlileage Charyes ~ 2.z.~ Subtotals $~pgp, ~ ~
<br />This is a c•°rtitied statement of miles drive `~, h,~ours spgn~ and~j~th ,~p enses while /sea~,rching '~r a replacement site.
<br />Total Claim $~ 10.'~• o'° ~/'Ll ~ 1/o~ri.~.~'~~G~~. _ gl~__ _~ So 3} S~'~ ~~° S 3-
<br />Comments to suppori claim appr:;~~al: /
<br />"T~,~, o ~ -~- -f / Q ~, s_~~-, ~7 c vp~s i ~ h ~j l /~...~e.r~~ a.,~.Q `n,~2c,t°/; -~, ~ a ~.s.e%~ _-~_
<br />-~ ~ -
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<br />t__ c~-„i,g~p S~v c.~.~i a~ sc -~i '6 ivr ~i .~ ~ y~vb v e. Ou iC _ u.a ~~_~-+~ ~.c%p- --
<br />T_~ ~y__ /~ A~ ~ / ~~D , .-. - 7S', ~~c- ~e .
<br />$ E A Agent's ignature ate
<br />Reviewefs S~g~ature Date
<br />Form 203 (7/95)
<br />RELOCATION
<br />StTE SEARCH CLAIM
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