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1. WAGES FOR HIRED M~, ~`~RS: Fili in dates, workers names, ours worked, and rate requested. <br />Attach proof of worker's wage rate. <br />Date Worker's Name Hours <br />Worked Hourly <br />Rate Total '~ <br /> <br /> <br /> <br /> <br />2. EQUIPM ENT RENTAL~ Fill in date used t f <br />~ , ype o equipment, hours used, and rate. Attach receipts <br />or other documentation df expense. ; <br />Date Equipment Used Hours <br />Used Hourly <br />Rate Total <br /> <br /> <br /> <br /> <br />'] !'1TLJC[~ [- vnr~inrn. r. _ ~ _ • <br />~. ~.~, .~iv ~~~v~v. vAIG~ ~C~~~~N~,un, ana cost must ne tii~ed m. Attach invoice or other <br />documentation of expense. <br />Date Description Cost Total <br />Form 223 (7/95) RELOCATION <br />ACTUAL COST NON-RESIDENTIAL MOVE CLAIM <br />