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~,. <br />Oregon Deparfinent of Transportation <br />Pay To: <br />Mailing Address: <br />Ciaimant's Name <br />RELOCATION <br />REESTABLISHMENT CLAIM <br />I claim the follovying costs incurred in relocating and reestablishing my small <br />business, farm or non-profit organization. I have attached actual receipts to <br />verify my expenses, and I have included written support for all Estimates. My <br />claim is based on the foliowing: <br />Repairs o~ improvements required by law, code, or ordinance. <br />Modifications to accomodate the business operation. <br />Construction and installation costs for exterior signing <br />Provision of utilities from right of way to improvements <br />Redecoration or replacement of soiled or worn surfaces <br />Licenses, fees and permits not paid as part of moving expenses <br />Feasibility surveys, soil testing and marketing surveys <br />Adve~tisement of replacement location <br />Professional services in connection with the purchase or lease of a <br />replacernent site. <br />Estimated inc~eased costs of operation during the first 2 years at <br />the replacement site for such items as : <br />A. Lease or rental charges <br />B. Personal or Real Property Taxes <br />C. Insurance Premiums <br />D. Utility Charges, excluding impact fees <br />Impact Fee or one-time assessments for anticpated heavy utility <br />usage <br />Other (explain) <br />Total (reimbursement not to exceed $10,000) <br />$ <br />$ <br />$ <br />$ - <br />$ <br />$ <br />$ ~ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />aiman igna ure <br />ae <br />$ E. A. <br />AgenYs Signature <br />Reviewer's Signature <br />Form 205 (11/95) <br />Oate <br />Date <br />RELOCATION <br />REESTABLISHMENT CLAIM <br />