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Oregon Department of Transportation <br />~ <br />RELOCATION <br />CLAIM FOR SIGN REMOVAL EXPENSES <br />(BASED ON SCHEDULE OR ESTIMATES) <br />Pay To: <br />Mailing Atldress <br />ClaimanYs Name <br />Sign at Milepost it S. ~ pertnit # <br />/ <br />I am applying for sign removal costs of $_____ <br />p The amount of this claim is based on the attached estimate(s). <br />p The amount of this claim is based on Page ______, Schedule ______ of the Oregon sign removai payment <br />schedules. <br />I understand that payment wiil be made directly to me after my sign(s) have been removed from the real property being <br />acquired by the Oregon Oepartment of Transportation and the property has been left clean, vacant, and orde~ly. <br />I also understand that payment of this claim will not be made until a release of the leasehold interest in that acquired property <br />has been executed. I agree that the sign(s) will not be moved to a new site in violation of State, Federal, or local regulations. <br />APPLICANT S~GNATURE <br />ADDRESS <br />c~n, srnre. ziP <br />OATE <br />File No <br />, Name <br />Sectio~ <br />Highway <br />County <br />FAP No. <br />INSPECTION REPORT <br />The subject property was inspected~on , and the sign site was found vacant, clean and orderty. <br />The sign has been relocated to a replacement site. I recommend the sign removal payment be released. <br />g t ay gent ate <br />Region Right of Way Supervisor's comments to support claim approval: <br />$ E. A. AgenYs Signature <br />Reviewe~s Signature <br />F«.T, 30, ~~rss~ <br />Oate <br />Oate <br />RELOCATION <br />CLAIM FOR SIGN REMOVAL EXPENSES <br />(BASED ON SCHEOULE OR ESTIMATES) <br />