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r <br />~ ~y ~.r% <br />• ~ Oregon Department of Transportation RELOCATION <br />RESIDENTIAL OCCUPANT INTERVIEW <br />^OWNE~ ~I'EN~-NT <br />Property Address r-~~p ~ ~ ~-(~2~ ~1 ~c'__ <br />Date of Occupancy_ ~~~~_Contract Rent'~~ <br />Attach copy of rental agreement or rent receipt <br />Estimated Monthly Utility Costs: <br />Electricity Heat <br />Water Sewer <br />SPECIAL RELOCATION NEEDS OF THE RELOCATEE: <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP No <br />UTILITY OF DISPLACEMENT DWELLING: <br />REPORT OF PERSONAL INTERVIEW: <br />,~ <br />Right of Way Agent. <br />Date <br />Form 101 (6/95) RELOCATION <br />RESIDENTIAL OCCUPANT INTERVIEW <br />ESTIMATED TOTAL GROSS MONTHLY HOUSEHOLD INCOME~~~a r~ Z7 -~ ~`PS <br />If rent + utilities is greater than 30% of the total gross household income, displacee must compiete <br />income verification form and provide complete state and federal returns. <br />