HomeMy WebLinkAboutREIMBURSEMENT PAPPERRECEI`: =D DEC 22 2015
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 5750023
APPLICATION AND CLAIM FOR REIMBURSEMENT OF MOVING COSTS RIGNTOF WAY
DWD
❑x PERSONAL PROPERTY ONLY
❑
INDNIDUAL_OR FAMILY-
❑
;BUSINESS
❑.
'FARM
❑
NONPROFIT
CLAIM TYPE APPLIED FOR:
❑ :COMMERCIAL MOVE
❑ MOVING RELATED EXPENSES
❑ SCHEDULE MOVE COSTS
❑ ;SELF MOVE
I] DIR LOSSISUB PROP/BULK-LOW VAL
❑ -SEARCH. EXPENSES
❑ .FIX PAYMENT IN LIEU.OF MOVE CST
x❑ REESTABLISHMENT EXPENSES
0 MOVE COST ESTIMATES
TOTAL AMOUNT CLAIMED
TOTAL AMOUNT ALLOWED
"OIFFERENCE
DARCEL VACATE DATE
IAAKE CHECK PAYABLE TO
BY
Sf. LUCI@ CaiInt1
Fort
Florida
5
S
5
5_
5 8.000.00
5
5
5 14.249.92
5
$ 22.249.92
$ 22,249.92
$ 000
Four
I HEREBY CERTIFY:
AU 'CLAIMANT CERTIFIES THAT HE/SHE IS A LEGAL RESIDENT OF THE UNITED STATES, AND UPON DEPARTMENTAL REQUEST CAN
�� P.ROVIDE DOCUMENTATION VERIFYING LEGAL RESIDENCY.
-) THE ABOVE INFORMATION AND ALL OTHER INFORMATION SUBMITTED HEREWITH ISTRUE AND CORRECT AND ACCURATELY
it-) REFLECT MOVING SERVICES ACTUALLY PERFORMED;
C . THAT NO REIMBURSEMENT OR COMPENSATION HAS BEEN RECEIVED FOR THE AMOUNT OF THIS CLAIM OR ANY PART THEREOF;
AND NONE IS CLAIMED OTHER THAN THE CLAIM HEREIN; AND
D. IF AN IN LIEU OF CLAIM IS SELECTED, THE CLAIMANT HAS NOT, NOR DOES HE/SHE INTEND TO AMEND OR REVISE THEINCOMETAX
RETURNS SUBMITTED HEREWITH; AND FURTHER CERTIFIES THAT THE CLAIMANT HAS NOT RECEIVED NOTICE OR OTHER
S INDICATION THAT SAID RETURNS ARE OR MAY INCORRECT.
E . • IF ADVANCE PAYMENT IS MADE PRIOR TO THE MOVE, THE CLAIMANT WILL COMPLY WITH FOOT RIGHT OF WAY RELOCATION
PROCEDURE 575-000-000, SECTION 9.3, PAYMENT FOR MOVING AND RELATED EXPENSES, IN THE MOVING OF PERSONALTY FROM
THE ACQUIRED PROPERTY. I. FURTHER CERTIFY THAT THIS PAYMENT SATISFIES ALL CLAIMS FOR ITEMS LISTED ON THIS CLAIM.
•F . THAT THIS PAYMENT SATISFIES ALL CLAIMS FOR REIMBURSEMENT FOR ITEMS, OR PARTS OF ITEMS, AS THEY ARE LISTED_ IN THIS
CLAIM;
G. CLAIMANTHAS BEEN ADVISED THEIR CLAIM WILL BE REVIEWED FOR APPROVAL OF PAYMENT WITHIN IO WORKING DAYS OF
RECEIPT BY THE DEPARTMENT AT ITS OFFICE LOCATED AT.' 3400 W.,Commercial Blvd. Fort Lauderdale, FL 33309
CLAIMANT NAME
REVIEWED:
APPROVED:
rs��r
. PROPERTY HAS BEEN REMOVED. OR WORK HAS BEEN COMPLETED, AS STATED.
IS ELIGIBLE FOR RELOCATION MOVING EXPENSES CLAIMED.
DATE
SIGNATURE TIRE DATE
" SIGNATURE - - TITLE
DATE