Laserfiche WebLink
~ ~~ ~ <br />Oregon Depai-tment of Transportation RELOCATION <br />LOSS OF TANGIBLE PERSONAL PROPFRTY <br />Pay To: <br />Mailing Address <br />~ Claimant's Name <br />MY CLAIM IS BAtSFI~ C~N THF Fn~ i n~nnnir_ <br />(rage 1 ot Z pages) <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP No. <br />Business Being Reestablished at New Location <br />items: <br />A. Replacement Cost, inciuding installation, less net proceeds of sale, or trade- <br />in allowance (Attach documentation) A. $ <br />B. State's estimated cost of moving (Attach estimates) g. ~ <br />Amount Ciaimed (lesser of A or B) $ <br />Business Being Discontinued or Items Not Being Replaced <br />Items: <br />A. State's estimate of fair market value in place, less net proceeds of sale <br />(Attach documentation) A. $ <br />B. State's estimated cost of moving (Attach estimates) g, $ <br />Amount Claimed (lesser of A or B) $ <br />Item(s) Not Sold - No Offer Received <br />Items: <br />A. State's estimate of fair market value in place (Attach documentation) <br />A. $ <br />B. Expense of Sale + State's estimated cost of moving (Attach documentation) B. $ <br />Amount Claimed (lesser of A or 6) $ <br />Total Amount <br />of Claim: $ <br />Claimant's Signature Date <br />Amount Approved E.A AgenYS Sig~ature Oate <br />Reiocation Reviewer Date <br />Form 206 (11/95) LOSS OF TANGIBLE PERSONAL PROPERTY <br />