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F Claim for Fixed Payment in Lieu of Actual Moving and Related Expenses <br />Nonpro <br />Business, Organizations Operations <br />fit <br /> <br />INSTRUCTIONS: This claim is for the use ordisplaceJ businesses, nonprofit <br />un,Uamans.:md from npe,atmns that sash to apply for a Fi-I Payment in Lieu or <br />Actual Moving Expenses raU:cf than apply for .Actual Moving Bitenses. The Agency: City of Santa Ana <br />minimum fixed payment is S 1,000 00, the nummtun fired payment is 5:0,000.00. <br />The Agency trill captain the difference: between the nco paymerts. lryou are <br />eligible to 6imw zither payment, the .Agency representative will kelp you determine Protect: Bristol Street Widening Project <br />U hich is most advNUacasus. and will help you complete the form. 11 the full amount <br /> <br />of your claun is not approved, the Agency q ill provide you with am riuen explanation <br />of the reason If you are net satisfied w ah the Agency's determination, you may Cage #' STA-036-01631-302 <br />appeal Utat dttermmanon. The ASency will explain how to make an appeal. This <br />ti <br />b <br />ll <br />h <br />h <br />i <br />y <br />f <br />h <br />if <br />R <br />l <br />i <br />f <br />i <br />i <br />d <br />d <br />U <br />eing co <br />ecte <br />un <br />er t <br />e aut <br />or <br />t <br />o <br />t <br />e <br />orm <br />e <br />oca <br />on <br />n <br />ormat <br />on <br />s <br />n <br />Assistance and Real Prapaty policies Act (URA) and'er California Relocation Program Rules: OPC Claim Serial Number: <br />Assistance acs. <br /> [ ] Federal [X] State [ )Other LG1302 <br />SECTION A: GENERAL <br />1. Name Under Which Claimant Conducts Operations- 2. Name, Title and Phone # of Person Filing Claim on Behalf of Claimant: <br />Raymond G. Mori - Law Office Raymond G. Mori -Attorney - 714/542-3966 <br />3a. Address From Which Claimant Moved: 3b. Date First Occupied: 3c. Date Move Started: <br />1631 N. Bristol, Ste. 302, Santa Ana 92706 1/111996 Pending <br />4a. Address to Which Claimant Moved: 4b. Date Move Completed: 5. Is This a Final Claim? <br />Pending Pending [x] Yes [ ] No <br />6. Type of Operation (Check One): 7. Type of Ownership (Check One): <br />[xJ Business [ ] Farm Operation [ J Nonprofit Operation [x] Sole Propriet. [ ] Corporation ( ) Partnership [ ] Nonprofit Org. <br />8. Computation of Payment <br />ITEM AMOUNT CLAIMED 1n):?I;1?1 ?E(u?Yd?) ; ?)tti ,', <br />(1) Amount from Line (3), (6), (9) or (12) of Section E on reverse. <br />(if less than $1,000 enter $1,000, if more than $20,000 enter $20,000) $20,000.00 <br />(2) Amount Previously Received for Expenses Claimed Here (if any) <br />(3) Amount Requeted (Line (1) minus Line (2)) $20,000.00 <br />9. Certification by Claimant(s) <br />Warrning: If you knowingly or deliberately make false statements on this form, you may be subject to civil or criminal penalties under Section 1001 of Title 18 of the United States Coda. In <br />addition, you may not receive any of the amounts claimed on this forth. I CERTIFY that this claim and supporting information are true and complete, that 1 have not submitted any other <br />claim for the expenses listed, and that I have not boon paid for the expenses by any other source. My choice of type of payment was made on the basis of full explanation by the displacing <br />Agency ropresentative the difference between the two typos of payment available and the eligibility requirements foreach. <br />Signature(s) of Claima <br />t(s) or Claimant(s) Agent): Title (Type or Print): Dale: <br />n <br />1, fV1---? Rc, rti..t}? C Rov_i 4f /-S <br />FOR AGENCY USE ONLY <br />Payment Action: Amount of Payment: Signature: Name (Type or Print). Dale: <br />10. Recommended $20,000.00 t ? Michele Folk 4/412011 <br /> PrincipalNice President <br />11. Approved $20,000.00 <br />overland, Pacific A Cutter, Inc. Page t of2 <br />25B-1 2 =BC-05 (4/O4)