Claim for Payment

CLAIM FOR PAYMENT

North Carolina Department of Transportation

relocation assistance

WBS Element: / County:
Claim Of: / TIP/Parcel No.
Displacee: / Displacee No.
Displaced Address
Replacement Address
Replacement Telephone / Date Property Vacated

Eligible for Last Resort

/ YES / NO / Status of Occupancy After / Owner / Tenant
NOTE: ALL PAYMENTS ARE CONDITIONAL UNTIL APPROVED BY THE RELOCATION COORDINATOR.
R E S I D E N T I A L / N O N - R E S I D E N T I A L
Replacement Housing Payment / Moving Costs / Moving Costs
Purchase / Fixed / Fixed Payment / M. H. Schedule
Rent / Actual / Actual Costs
Down Payment / MH Fixed / Self Move / Bid / Negotiated
Increased Interest / Schedule / Reestablishment
Closing Cost / Direct Loss of Tangible Personal Property
Searching Payment
Total / Total / Total
CERTIFICATION OF DISPLACEE
I hereby request a payment for replacement housing under the circumstances specified above, and state that I was an occupant of the above parcel. To the best of my knowledge, I am eligible for this payment, and replacement unit meets the requirements for decent, safe, and sanitary housing. THIS PAYMENT IS TO BE USED FOR HOUSING AND/OR UTILITIES COSTS ONLY.
/ I hereby certify to the North Carolina Department of Transportation the above information is correct, that I have completed my move as indicated above, and I have not been previously reimbursed for this moving expense. The items moved were classed as personal property and the State is hereby released from payment as realty.
I Hereby certify that all persons receiving the above listed payments are either a citizen or national of the united States or an alien who is lawfully present in the United States and in the case of a business or corporation is authorized to conduct business within the United States
obtaining money under false pretenses is a violation of general statues 14-100 and upon conviction is punishable by up to 10 years in prison or a fine in the discretion of the court.
Signature of Displacee(s)(and title, if corporate officer) / Date
CERTIFICATION OF RIGHT OF WAY AGENT
I hereby request a payment for housing that, to the best of my knowledge, meets decent, safe, and sanitary conditions. / I have personally verified the moving (including reinstallation) of personal property as herein claimed, and hereby recommend payment.
I further certify that I have no direct or indirect, present or contemplated personal interest in this transaction, nor will I derive any personal benefit from this payment. I also understand this determination may be used for a Federal-Aid highway project.
Signature of RW Agent / Date
Approval by Division Right of Way Agent or Consultant Project Manager / Date
Date Claim Received / Total Amount Approved
$

Final Payment

Approval by Relocation Coordinator: / Date:

FRM15-K 7-7-14