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~. <br />Oregon Department of Transportation <br />Pay To: <br />Mailing Address <br />Claimant's Name <br />RELOCATION <br />Actual Cost Non-residential Move Claim <br />tapp~~cation ror Hciua~ ~os~ Move Non-Kesidential Only I choose to move myself and hereby make <br />application to be reimbursed for my actual reasonable moving expenses. i understand that this move option is <br />only available under special circumstances and that I must have prior approval from the Relocation <br />Supervisor before I may claim reimburseme~t of my moving expenses. In addition, if this move option is <br />approved, the actual cost (sel~ move must be monitored by the Right of Way Agent. <br />I understand reimbursement wili not be made unless the Right of Way Agent is notified in advance of the move <br />and is given enough notice to extensively monitor the move. Eligibie expenses may include truck or cargo <br />trailer rental, special moving equipment rental, and wages for hired movers. All expenses must be supported <br />by paid invoices or other documentation. No payment may be made for the time spent by the displacee or <br />the displacee's family. An actual cost move is necessary because: <br />Claimant Signature <br />Date Approved By: Relocation Supervisor Date <br />Claim for Reimbursement of Self Move (Use additional sheets if necessary) <br />I claim reimbursement for my actual and reasonable expenses incurred while moving my personal property <br />from: A breakdown of <br />my actual expenses is on the back of this form or attached. I have attached documentation or other proof of <br />these expenses. I certify that this claim is correct and that the expenses claimed are actual, reasonable and <br />necessary. The move has been completed, and the vacated premises a~e in a cfean and orderly condition. <br />TOTAL CLAIM $ <br />T~... .... _~ ~~ <br />Claimant Signature <br />~~-~ ~~ ~~ ~~ N~~ ~~~ ~a~ N~ ~NC~ ~y ~rvrn ~ne suo~ect property has been monitored. An inspection of the subject <br />prope~ty was made on and found to be clean, vacant and orderly. Attached is a copy of the <br />signed move monitoring report. I recommend payment in the amount of ~ be released. <br />$ E. A. <br />Form 223 (7/95) <br />Agent's Signature <br />Date <br />Date <br />Reviewer's Signature <br />Oate <br />RELOCATION <br />ACTUAL COST NON-RESIDENTIAL MOVE CLAIM <br />