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. <br />~ <br />~ 0~~ <br />U.S. Dspartmsrtt ot Housiny ~ ~ <br />and Urban DevMopmeM <br />OMB Approvai No. 250fr0016 (exp. t t/30/90) <br />Ciaim for Moving and Related Expenses <br />Famllies and Individuals <br />For Agency Use <br />Name ol Apsncy ^ _ ~ r;~n ~O' `~ L` ,.. , .~ , , ln <br />~'~ 1~ ~~ ~ t'~«.c~:uy y~ <br />~~ <br />t Name or Number I~e NumDe~ <br />~e~~or A~A~~mFn~' ~-3~~0 <br />Pubilc reportinq burden for t~la collsction of Informatlon ia estimatsd to avx~qe 0.5 ~ouro per raaponae, inctu0lnq the time for reviewinp inatructlone, searchinp exietinp tlata sourcen, <br />palnerinq ind mNnlNnlnp the Cata n!lOetl, !ntl cOmD~sfinp Md rovf~winp tM COIIeCtlon ot Inlortn~tlon. $AnG eommMb npLdinp thla buWen satimate or Any other eeppCt ot this <br />coilxtlon of Infortnatlon, Includlnp auqqeatione 1or rsauefnp thla buMan, to ths Rsports Manapsment Officer, Offica ol Informatlon Polfeiea an0 Systems, U.S. DsDartment ol Houainq <br />end Urb~n psv~lopmsnt, WuNlnQton, D.C. 2041pJ600 and to t~s Ottie~ of Manapsmsnt and BuEqet, Paperwork RsOuetfon Pro~eet (2506-0018), Wunin9ton, D.C. 20503. <br />Prfv~ey Aa Notie~ Thia lnfortnatlon Is needed to detertnine whether you are eilgible to recelve a payment for movl~g and related expenses. You are not required <br />Dy law to fumfsh this Infortnation, but if you do not provide it, you may not receive any payment for these expenses or it may take longer to pay you. This <br />Infortnatlon Is beiny collected under the authority of the Unifortn Reiocatlon Aasistance and Real Property Acquialtion Policles ACt of 1970. The Informatlon may <br />be made avallable to a Federal apency for review. <br />Instrudbnc This clalm form fs for the uae of famllies and indNfduala applyinp for payment of moving and related expensea. You may apply for elther (1) a fixed <br />allowance, or (2) an amount ta cover the actual movt~q anG related expenses f~curred (es desc~ibed on pape 2 of this form). A clalm for actual expenses muat be <br />supported by recelpts or other evidence. The Age~cy wlll explain tM differencea between the two cypes of payments and wlll help you complete thfs fortn. If the <br />full amount Of your elaim IS not apprpved, the Agency wlll provide you with a written explanatior. of the reason. If you are not satlsfied with the AqenCy's <br />determinatlon, you may appeal that detertnfnation. The Apency wfll explain how to make an appeal. <br />~. Your Nam e) (YOU are the G~m~nt(s)) 1~. Pnssnt Mallin ACOress(ssl of Gdmanpa) 1D. Telsplw~s NumbeKs) <br />~~onC~~c~ ~,,~Ut12S ~"~ N -~S~-~N~ ~(l~ <br />2. Have All Members of the Household Moved to the Same Dwelling? ^ Yes ^ No <br />(If "No", list the names of all members and the addresses to which they moved in the Remarks Section.) <br /> <br />DwNlinp <br />Atltlress (Inciuds AD+rtmsnt No.) ~ Mow Many <br />Rooms Did <br />You OCeuDY?~ Was It Fumial+etl• <br />Wlth Vour Own <br />Furniture? When Ditl You <br />Move To <br />This Unit? <br /> Se~~a r • <br />N~ <br />' <br />-~ <br />P <br />~~ D <br />3. Unit That You <br />M <br />F ~~g Nj <br />i <br />5 <br />. <br />1 <br />~ ~ Yes ^ No g_3,C~ ~ <br />oved <br />rom ~~~ <br />D~ Q~~ I ( <br />4. Unit Thet YOU 'Exclutlinq bathrooms, <br />MOVed To na~iw~ys ana dossta. <br />5. Is This a Final Claim? $f Yes ^ No (If "No", Explain in Remarlcs Section) <br />6. Computatlon oi Payment (Complete Item 6a or 6b) • <br />Item 6a. Fixed Allowance 6b. Actual Moving <br />Expenses For A snc Uss Onl <br />g y y <br />(1) Moving Cost S S <br />(~ Transportation Cost - Families and Individuals <br />(3) Cost ot Insurance Covering Move andfo~ Storage <br />(4) Storage Cost (Complete Item 10 on page 2) <br />(5) Other (Explain in Remarks Section) <br />(6) Total Amount of Claim ~cor,sui~ ~oa+cy +a arr,a,o~ o+ n:so rwwaneel S ~~~ S S <br />(~ Amount Previously Received (If any) <br />(8) Amount Requested (Subtract line (7) from Line (6)) S S S <br />7. CerttHcatbn By ClaimaM(s) <br />Warnlny: if you knowinqly maks false stetsmeMS on this form, you may be wbject to civil a c~iminat psnskies und~r Sectbn 1001 of Titls 18 ot the <br />Unk~d States Code. In addiUon you may not ncNv~ any of th~ amowKS clalmsd on this form. <br />1 Certify that this clafm and supporting information are true and complete and that I have not been patd for these expenses by any other <br />source. I ask that the amount on Line (8) of Item 6 be pafd directly to ^ me ^ the contractor(s) (as specified in the Remarks Section). <br />Payment Actlon Amount of Payment Signature Name (Type or Print) Date <br />8. Recommended S <br />9. Approved S <br />Page t ot 2 fo-m HUD-40054 (1/90) <br />ref. Handbook 1378 <br />