Fillable Claim For Temporary Relocation printable pdf download

Claim for Temporary Relocation

U.S. Department of Housing and Urban Development

OMB Approval No. 2506-0016

Expenses (Residential Moves)

Office of Community Planning and Development

(exp. 10/31/2011)

(Appendix A, 49 CFR 24.2(a)(9)(ii)(D))

See page 3 for Public Reporting Burden and Privacy Act Statements before completing this form

Project Name or Number

Case Number

For Agency

Name of Agency

Use Only

Instructions: This claim form is for the use of families and individuals applying for reimbursement of temporary relocation expenses. The Agency will assist you in

completing the form. If the full amount of your claim is not approved, the Agency will provide you with a written explanation of the reason. If you are not satisfied with

the Agency’s determination, you may appeal that determination. The Agency will explain how to make an appeal. The Department of Housing and Urban Development

provides information on these requirements and other guidance materials on its website at

1a. Your Name(s) (You are the Claimant(s)) and Present Mailing Address

1b. Telephone Number(s)

2a. Have all members of the household moved to the same dwelling?

2b. Do you (or will you) receive a Federal, State, or

□ Yes □ No (If “No,” list the names of all members and the addresses

local housing program subsidy at the dwelling you

to which they moved in the Remarks Section.)

moved to?

□ Yes □ No

Dwelling

Address

When Did You

Rent This Unit?

Move to This

Move Out of This

Unit?

3. Unit That You Moved From

4. Unit That You Moved To

5. Unit That You Returned To

6. CERTIFICATION OF LEGAL RESIDENCY IN THE UNITED STATES (Please read instructions below before completing this section.)

Instructions: To qualify for relocation advisory services or relocation payments authorized by the Uniform Relocation Assistance and Real Property Acquisition

Policies Act of 1970, you must be a United States citizen or national, or an alien lawfully present in the United States. The certification below must be completed in

order to receive any relocation assistance. (This certification may not have any standing with regard to applicable State laws providing relocation assistance.) Your

signature on this claim form constitutes certification. See 49 CFR 24.208(g) and (h) for hardship exceptions.

Please address only the category (individual or family) that describes your occupancy status. For Line (2), please fill in the correct number of persons.

RESIDENTIAL HOUSEHOLDS

(1) Individual.

(2) Family.

I certify that I am: (check one)

I certify that there are _____ persons in my household and that ______ are

_____ a citizen or national of the United States

citizens or nationals of the United States and _____ are aliens lawfully

_____ an alien lawfully present in the United States

present in the United States.

7. DETERMINATION OF MOVING EXPENSES – MOVE TO TEMPORARY UNIT

Instructions: You may be eligible for reimbursement of actual and reasonable moving costs and related expenses in connection with your move to a temporary housing

unit. The computation table below provides you with the ability to compute your payment.

(1)

(2)

Commercial Move

Self Move

Move to Temporary Unit

(Actual Costs)

(Not to exceed cost paid by a

commercial mover)

Claimant

Agency Use

Claimant