Claim For Temporary Relocation Page 4
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4[CONTINUATION SHEET]
Claim for Temporary Relocation
U.S. Department of Housing and Urban Development
Expenses (Residential Moves)
Office of Community Planning and Development
(Appendix A, 49 CFR 24.2(a)(9)(ii)(D))
10. CONTINUATION SHEET FOR EACH ADDITIONAL MONTH OF 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 (i) must reflect all utility services. Therefore, identify on Lines 10(b) through 10 (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 10(h).
Temporary Relocation Cost for Periods That
Unit You
Unit You
Increase In
Amount Approved
Exceed One Month
Moved From
Moved To
Monthly Cost
(For temporary relocation that lasts more than one
(1)
(2)
(3)
(4)
(5)
(6)
month, complete this Continuation Form for each
Claimant
For Agency
Claimant
For Agency
For Agency
To Be Provided by
additional month of temporary relocation.
Use Only
Use Only
Use Only
Agency
(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 Lines 10 (b) to
10(f) below)
$
$
$
$
$
$
(b) Electricity
$
$
$
$
$
$
(c) Gas
$
$
$
$
$
$
(d) Water/sewer
$
$
$
$
$
$
(e) Sanitation
$
$
$
$
$
$
(f) Other
$
$
$
$
$
$
(g) Gross Monthly Rent and Utility
Costs (add Lines 10(a) through 10(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 20(h) from Line 10(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.
(1)
(2)
Monthly Cost For Month of: ______________________ _______
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)
$
$
(n) Total (add lines 10(j) through 10(m))
$
$
Page 4 of 4
Form HUD-40030 10/2008
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