Financial- Vandermay Law Firm (Previous Tenant)

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Oregon Department of Transporfation Agent's Signature FIXED PAYMENT CLAIM Pay To: Mailing Address Claimant's Name RELOCATION File No. Name Section Highway County FAP No. I, , Proprietor of located at hereby make application for Fixed Payment in lieu of moving expenses as a displaced ^ business, p farm, p non-profit organization (NPO). I understand that to be eligible for the fixed payment, I cannot be relocated without a substantial loss of existing patronage; and further to be eligible, I must not be a pa~t of a commercial enterprise having more than three other entities which are not being acquired by the State, and which are under the same ownership and engaged in the same or similar business activities. I undertand that the fixed payment is to be based on one-half the "annual net earnings" before Federal State, and local income taxes during the two taxable years immediately preceding the tax year of displacement, not less than $1,000 nor more than $20,000. I understand that the amount of payment I receive will be computed from the Oregon Income tax returns filed by myself, copies of which are attached. I understand that the fixed payment is in lieu of all other relocation benefits and that the premises must be vacated and left clean arrd orderly. I certify that I am the proprietor and have operated the business, farm, or NPO for months and that the statements contained herein are true and correct to the best of my knowledge and belief. Based on the above, I claim a fixed payment of $ Appllcant Oate Applicant Date The subject property was inspected on and found to be vacant, clean, and orderly. An inspection of the proprietor's Oregon Income Tax returns indicates that the proprietor should receive payment. I recommend that the proprietor be paid the sum of $ A E $ . . . Form 204 (11/95) Date Reviewers Signature Oate RELOCATION FIXED PAYMENT APPLICATION Page 3 of 2 pages