Claim For Temporary Relocation Page 2

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8. DETERMINATION OF MOVING EXPENSES – MOVE TO PERMANENT UNIT
Instructions: You may be eligible for reimbursement of actual and reasonable moving costs and related expenses in connection with your move to a permanent housing
unit. The computation table below provides you with the ability to compute your payment.
(1)
(2)
Commercial Move
Self Move
Move to Permanent Unit
(Actual Costs)
(Actual Costs) (Not to exceed
cost paid by a commercial
mover)
Claimant
Agency Use
Claimant
Agency Use
(a) Moving Cost Expenses (49 CFR 24.301(g)(1-7)); see page 3
$
$
$
$
(b) Telephone re-connection
$
$
$
$
(c) Cable/Internet re-connection
$
$
$
$
(d) Other (Explain in Remarks Section)
$
$
$
$
(e) Total (Lines 8(a) – 8(d))
$
$
$
$
(f) Amount Previously Received, if any
$
$
$
$
(g) Amount Requested (Subtract Line 8(f) from Line 8(e)
$
$
$
$
(h) Total Amount Approved by Agency (for move to permanent unit)
$
$
TO BE COMPLETED BY AGENCY
SUMMARY FOR MOVE TO PERMANENT UNIT
Line No.:
Amount Claimed:
Amount Recommended:
Date Paid:
Payable To:
(i) Line 8(h), Column (1)
$
$
(j) Line 8(h), Column (2)
$
$
(k) Total:
$
$
Payment Action
Amount of Payment
Signature
Name (Type or Print)
Date (mm/dd/yyyy)
(l) RECOMMENDED
$
$
(m) APPROVED
$
$
Remarks (Attach additional sheets, if necessary)
9. MONTHLY OUT-OF-POCKET COSTS FOR TEMPORARY RELOCATION
Costs listed on this form are for the period beginning ____________ _______ and ending _____________ ________ TOTAL # OF MONTHS: _____
(Month/Day)
(Year)
(Month/Day)
(Year)
DETERMINATION OF RENT AND AVERAGE MONTHLY UTILITY COSTS
Instructions: To compute the payment, entries on Line 9(i) must reflect all utility services. Therefore, identify on Lines 9(b) through 9(f) each utility necessary to
provide electricity, gas, other heating/cooking fuels, water and sewer. In those cases where the utility service is covered by the monthly rent, enter “IMR” (In Monthly
Rent). If a monthly housing program subsidy (e.g., Housing Choice Voucher/Section 8, other) has been provided, enter the applicable amount on Line 9(h).
Unit You
Unit You
Increase In
Amount Approved
Monthly Temporary Relocation Cost
Moved From
Moved To
Monthly Cost
(For temporary relocation that lasts more than one
(1)
(2)
(3)
(4)
(5)
(6)
month, either complete a Continuation Form for each
Claimant
For Agency
Claimant
For Agency
For Agency
To Be Provided by
additional month of temporary relocation or enter total
Use Only
Use Only
Use Only
Agency
claimed on Line 9(p) and explain under “Remarks.”
(a) Rent (The monthly rental amount due under the
terms and conditions of occupancy).
Check appropriate box:
□ All utilities included
□ Utilities not included (list on Line 9(b) to 9(f)
below)
$
$
$
$
$
$
(b) Electricity
$
$
$
$
$
$
(c) Gas
$
$
$
$
$
$
(d) Water/sewer
$
$
$
$
$
$
(e) Sanitation
$
$
$
$
$
$
(f) Other
$
$
$
$
$
$
(g) Gross Monthly Rent and Utility
Costs (add Lines 9(a) through 9(f))
$
$
$
$
$
$
(h) Monthly Housing Subsidy, if
applicable (e.g., Housing Choice
Voucher/Section 8, other)
$
$
$
$
$
$
(i) Net Monthly Rent and Utility Costs for Month of
________ (subtract Line 9(h) from Line 9(g)
above)
$
$
$
$
$
$
OTHER REASONABLE OUT-OF-POCKET EXPENSES
Instructions: You may be eligible for other reasonable out-of-pocket expenses as approved by the agency in connection with your temporary move.
Monthly Cost For Month of: ____________________ _______
(1)
(2)
Claimant
Agency Use
(Month)
(Year)
(j) Per Diem for unit without cooking facilities:
$__________ per adult x ______ days in this month period
$__________ per child under age 12 x ______ days in this month period
$
$
Other (e.g., increased transportation costs, boarding for pets, parking). Itemize.
(k)
$
$
(l)
$
$
(m)
$
$
Page 2 of 4
Form HUD-40030 10/2008

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