Trade Adjustment Assistance Relocation Allowance Reconciliation

I. General Information

Participant Name / Relocation Departure Date
State ID / Relocation Departure Time / AM PM
Petition Number / Relocation Distance / miles
Date of Reconciliation
Number of miles (relocation distance per MapQuest)
X
Federal mileage reimbursement rate. / Either the actual cost of lodging or 50% of the Federal per diem rate for the area, whichever is less. / Either the actual cost of meals or 50% of the Federal per diem rate for the area, whichever is less.
II.  Actual Travel Costs / / /
Family Member Name / Relationship to Participant / Ticket Fee
Air Fare
Bus
Other / Mileage
Costs / Lodging Costs / Meal Costs / Other / Travel Cost per Family Member
$ / $ / $ / $ / $ / $
$ / $ / $ / $ / $ / $
$ / $ / $ / $ / $ / $
$ / $ / $ / $ / $ / $
$ / $ / $ / $ / $ / $
(Continue on separate sheet, if necessary.) / Total Travel Costs / $

III.  Actual Moving Costs

Commercial Carrier (Up to 18,000 lbs.)
Moving Cost / $
Carrier Insurance (Not to exceed $50; may be used in lieu of cost of independent insurance.) / $
Accessorial Charges (Include the cost of insuring HHGs and effects for their actual value or $10,000, whichever is least, against loss or damage in transit, if a bid from a licensed insurer is obtained by the individual and approved by the State agency before departure.) / $
Trailer and Truck Rental (Up to 18,000 lbs.)
Rental Fee (truck, trailer, towing, cargo van, portable container, etc.) / $
Fuel (rental truck, cargo van, etc.) / $
Delivery & Pickup (portable container, trailer, etc.) / $
Moving Supplies (boxes, tape, packaging supplies, etc.) / $
Other: / $
Moving a House Trailer or Mobile Home (Up to 18,000 lbs.)
House trailer or mobile home moving charge / $
Unblocking & Re-blocking moving house trailer or mobile home / $
Ferry charges, bridge, road, and tunnel tolls, taxes, fees fixed by a State or local authority for permits to transport the unit in or through its jurisdiction, and retention of necessary flagmen / $
Carrier Insurance (Not to exceed $50; may be used in lieu of cost of independent insurance.) / $
Accessorial Charges (Include the cost of insuring HHGs and effects for their actual value or $10,000, whichever is least, against loss or damage in transit, if a bid from a licensed insurer is obtained by the individual and approved by the State agency before departure.) / $
Other: / $
Storage Costs (60 Day Maximum) / $
Total Moving Costs / $

This Relocation Allowance Reconciliation was completed and reviewed by:

Case Manager Name / Case Manager Signature / Date
By signing below, I affirm the following:
1.  All information provided above is true and accurate to the best of my knowledge.
2.  I understand that giving any false information or withholding information in order to obtain or increase benefits is FRAUD and can subject me to liability to repay overpayments, program disqualification, and criminal prosecution with penalties ranging from fines to up to 10 years imprisonment.
3.  I must provide all necessary documentation, including but not limited to valid receipts and/or proof of payments.
______
Participant Signature Date

IV.  Payment Reconciliation (For TAA Accounts Payable Staff Only)

Total Cost / $
Total Approved Amount (90% of Total Cost) / $
Contribution(s) From Other Sources * / ($ )
Total Amount Advanced / ($ )

* The total Relocation Allowance must be reduced by any amount the individual is entitled to be paid or reimbursed from any other source(s).

Determination (A): Amount Due to Participant: $______
Determination (B): Amount Due to the South Carolina Department of Employment and Workforce: $______
Please make checks payable to: South Carolina Department of Employment and Workforce
(Include copy of determination) Trade Adjustment Assistance
Post Office Box 1406
Columbia, SC 29202
______
Accounts Payable Signature Date
APPEAL RIGHTS – IF YOU DISAGREE WITH ANY DETERMINATIONS, YOU HAVE THE RIGHT TO APPEAL. DETERMINATION (A) MUST BE APPEALED WITHIN TEN (10) CALENDAR DAYS OF CHECK ISSUANCE. DETERMINATION (B) MUST BE APPEALED WITHIN TEN (10) CALENDAR DAYS FROM THE DATE OF THE PAYMENT DETERMINATION. ALL APPEAL TIME FRAMES INCLUDE WEEKENDS AND HOLIDAYS; IF THE TENTH (10TH) DAY FALLS ON A SATURDAY, SUNDAY, OR HOLIDAY, THE APPEAL PERIOD IS EXTENDED TO THE NEXT BUSINESS DAY. YOUR APPEAL MAY BE FILED IN PERSON OR BY MAIL ADDRESSED TO APPEAL TRIBUNAL, P.O. BOX 995, COLUMBIA, SC 29202.

Rev. 4/14

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