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~ Appent~l l. llandbook 1378 CIIC-1 * - Claim for Moving and U.S. Department ot Houstng ~\ and Urban Development ~ Related Expenses -- , r Families and Individuals OMB Approval No. 2506-0016 (Exp. 11~O19p) Fot Aganey Nama ol Apency: Prqact Name a Number. Cus Number: UseOnly:~~~,~, ~(.~~ ~' ~,~1 .,y ` •~( 1..~`;'~` ~LtI~J ~~ Publlc Reporting Burden tor this collection al informaoon is estimated to average 0.5 hours per response, includ'ing the time for reviewing instrvctions, searching existing data so~~rces, gatharing and maintaimng the data needed, and completing and reviewing tho collection ot intormaoon. Send comments regar6ng this burden estimaie a any other aspect ol this colledan et informabon, including su99estions lor reducing this burden, to the Reports Management OHicer, Oflice ot Inlwmaaon Folicies and Systems, U.S. Department of Nousing and Urban Oevebpmen4 Washington, O.C. 20d 103600 and w tho Office of Management and Budget, Paperwork ReducGon Project (2506-OOt6), Washington, D.C. 20503. Do not send this completed form to either of these addressees. In structions: This claim torm is fa the use ot famil'~es and individuals t+pplying (or payment of moving and related expenses. You may apply ta either (i ) a fixed allowance, or (2) an amount to cover the actual moving and related expenses inwrred (as desuibed o~ page 2 0! this lorm). A claim for acNal expenses must be supponed by receipts or other evidence. The Agenry will explain tfie diflerences beMreen the two types of payments and will help you complete this torm. If the full amount of your claim is not approved, Me Agency will provide you witl~ a written explanation of the reason. If you are not sa0s('~ed with the AgencYs determination, you may appeal that detertnination. The Agency wip explain how to make an appeal. t. Your Name(s) (YOU are the C~aimant(s)) ~ ta. Present MaiG Addreu(e 1 C~a~ qsl tb. TNepnone Numbe.(s) ~ ~ a.~ ~~~~ ~~~ 2. Ha~mber~Household Moved to the Same Owelling? Yes ~~ No (It 'No,' list the names of alf inembero and the addresses to which they moved in the Remarks Sectan.) -- ---- How Many fiooms was It fumishsd w~m When Ua vou ~ Addrcss (indud~ Apartmant No.) I OiC You Oavpy? ' Yow Own Furnituro? Move ro TNS Unit? _Oweltiry . - T'~:,1~5 ~~~-~~__''~~~ a5 3. Unit That You ~^~ ~~ ,` `U ~es ~No ~Z,~~`\ Moved From ~~~ Q 1J~. v~ r~' <. Unit That You i I ' Exdudinq baWooms. Moved To , hallways and tbs~u. 5. Is This a Finzl Claim? ~ s ;_ No b. Computatian of P,dyment (coc+otace Rem 6a a 6b1 ~ Ittm I Ba. Fi:ed Albwante Bb. Attual Mov'v+ Ecpenses For A•nc Us~ Onl (t) Noving Cost S S (2) Transaortation Cost-Families and Individuals (3) Cost ol lnsurance Cave~ing Mo~:e and/or Sto~age / ~ (a) Storage Cost (Complate Item 10 on paye 2) j ~// / (5) Other (Explain in Remarks Secuon) / ///i.~~~~ (6) TotAI Amount of Cl~im (Cors~lt Aqency f~~ amount o~ ~~=ed a~bwance) i S a~~ .v~ ~_ ~ s _ ,_ -_ ~ (7) Amou~t ?reviously Rea:ived, if any - I _ - _ -~- --°-°- -._!- ~ (8) Amount Rt~~ested (Svbtraa fr.e (7) I:cm ii:w (6)) ! S I S S 7.Certif~cation By Claimant(s): I cert~y that this claim and suppoAing inlormation are we and complete and that 1 have not been paid lor these expenses by anp other source. I asR that the amount on tine (8) ol Item 6 be paid direcdy to ~me f~Cie oontracWr(s) (as specilied in the Remarlcs Section). 5•~naw~e(s) ol Cla~mant(s) 6 Oate: X ~ l~l J~w ~ ~_ r ~~~ .U~.A l)~ Y/'v Warning: HUD will prosecute false claims and statements. Conviction may result i~ criminal and/or civil penalties. (18 U.S.C.1001,10~0.1012:31 U.S.C.3i29, 38J2~ To Be Completed by tho Agency ! S~ rature ' Name (Troe or Prn1) I Daie Pay~*cnt Acoo^ ~ AToun~ ol Pay~+°nt 9~ --•-_-~- ~ - --- ~ __~_.._--•-------~-- ._. --'- °_-.._ _. ..... . _ _._... - - - ~ ( 1 8 Recommend~~d ' S ~ I ~ ~ ' --- --------- --T---- --- ---- . _ . ~ -- -. . _._._ . ---•__.._.. --- ~ I 9 Approved S I ~ i ' Page t o: 2 lorm HUD-40054 (1/S2) ret Handbook 137@