Unit Record
Route / Project
Section / Job No.
County / Parcel / Unit
Residential / Business / Farm Operation / Nonprofit Organization
Offer Made / First Contact / File Closed
Person Interviewed / Interviewed By
Name
Address / Telephone No. / ( )
Cell No. / ( )
City / State / Zip
Members of Household
Last Name / First Name / SS/FEIN No. / Age / Sex / Race
FM / Am. Indian/Ala. NativeAsian or Pacific IslanderBlackSpanish or HispanicWhiteOther
FM / Am. Indian/Ala. NativeAsian or Pacific IslanderBlackSpanish or HispanicWhiteOther
FM / Am. Indian/Ala. NativeAsian or Pacific IslanderBlackSpanish or HispanicWhiteOther
FM / Am. Indian/Ala. NativeAsian or Pacific IslanderBlackSpanish or HispanicWhiteOther
FM / Am. Indian/Ala. NativeAsian or Pacific IslanderBlackSpanish or HispanicWhiteOther
FM / Am. Indian/Ala. NativeAsian or Pacific IslanderBlackSpanish or HispanicWhiteOther
FM / Am. Indian/Ala. NativeAsian or Pacific IslanderBlackSpanish or HispanicWhiteOther
Remarks: (Family composition, special needs, etc.)
RHP Eligibility
Rent PurchaseComputation Date / Amount / $
Housing of Last Resort Yes No / Central Office Approval Date
Existing Residence
Occupancy Date / Occupancy Status / 90-Day Owner Occupant90-Day OccupantLess than 90-Day
Type of Dwelling / Own Rent
Dwelling Value / Monthly Rent / $
Number of Rooms / Bedrooms / Baths
Replacement Dwelling Desired
Assistance Requested Yes No
Desired Relocation Area / Type of Dwelling Type
Number of Rooms / Bedrooms / Baths
Special Features Required
Price Range of House / $ / to / $
Maximum Monthly Principal and Interest or Rent Payment / $
Replacement Business Desired
Desired Relocation Area
Type of Property
Special Features Required
Replacement Property
30-Day Notice Sent / DSS Inspection Date
Date Relocated
Address
Telephone No. / ( )
City / State / Zip
Relocation Payment Record
Type / Subtype/
Function
Code / Amount / Claim
Date / Notice of
Receipt
Date / Sent to
Springfield
Date / Schedule
Number / Schedule
Date
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
ClosingIncidentalIn-LieuMIDPMovingReestablishmentRHPSearching / $
District Remarks:
Referrals
Date / Address / No. of Rooms or
Sq. Ft of Area / Asking Price
or Rent / Disposition
Narrative Log: (Date, summary of action or activity and initials of writer for each contact with the relocatee is required.)
Date / Summary of Action / Initials
Printed 9/17/2018Page 1 of 3LA 541D (Rev. 10/01/14)