MORI, RAYMOND G. - 2011 - Laserfiche WebLink

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=BC -us (4;04) INSTRUCTIONS: This claim is for the use of displaced 'businesses, nonprofit '(.t-i'[ t t vs3 �k� 1 i` yx- "t5 k r s k-t !".f -. s t, � a � organizations, a:mi from operrnnns chat wish to a;rplg far a Fix,,l Payment in 1 leu of :. ,r- ..- .. - - - Actual h10ving Expenses rather that apply for .actual \ioring Expenses - 'rhe Agency: City of Santa Ana minimum fixcd payment is $1,600 00, tltentasirnum fixed payment is 520,000.00, 'Fite Agency will explain the diff reners beacee» the tsro paymerts. If you are Praect: Bristol Street Widening Project eligible tochoose either Payment, the Agency representative will help yet, deemtine w [rich is most advantageous, and » ill h0, Ip you complete the form. If the full amount ofyour claim is not approved, the Agency vv ill provide you with a written explanation Case #: STA-036-01631-302 of Uta reason. If vett are not satisfied rcith the Agency's delemtinauon, you may oppcai that determination. The Agency v:ill explain how m make an appeal. This information is being collected under the authority of the Uniforin Relocation Assistance.:nd Real Prt ity Policies Act (URA) and'or Cahfom;a Relocation Assistance Act. Program Rules: OPC Claim Serial Number: [ j Federal (Xj State [ j Other LG1302 SECTION A: GENERAL 1. Name Under Which Claimant Conducts Operations: 2. Name, Title and Phone # of Person Filing Claim on Behalf of Claimant: Raymond G. Mori - Law Office Raymond G. Mori -Attorney - 7141542-3966 3a. Address From Which Claimant Moved: 3b. Date First Occupied: 3c. Date Move Started: 1631 N. Bristol, Ste. 302, Santa Ana 92706 1/111995 Pending 4a, Address to Which Claimant Moved: 4b. Date Move Completed: 5. Is This a Final Claim? Pending Pending [x] Yes [ ] No 6. Type of Operation (Check One): 7. Type of Ownership (Check One): [xj Business [ j Farm Operation [ j Nonprofit Operation [x] Sole Propriet. ( ] Corporation [ j Partnership ( j Nonprofit Org, 8. Computation of Payment ITEM AMOUNT CLAIMED (1) Amount from Line (3), (6), (9) or (12) of Section E on reverse. (if less than $1,000 enter $1,000, if more than $20,000 enter $20,000) $20,000.00 (2) Amount Previously Received for Expenses Claimed Here (if any) (3) Amount Requeted (Line (1) minus Line (2)) $20,000.00 9. Certification by Claimant(s) Warning: 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 Code. In addition, you may not receive any of the amounts claimed on this form. i CERTIFY that this claim and supporting information are true and complete, that i have not submitted any othe claim for the expenses listed, and That I have not been 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 Agency representative the difference between the two types of available payment and the eligibility requirements for each. Signature(s) of Claimant(s) or Claimant(s) Agent): Title (Type or Print): Date: FOR AGENCY USE ONLY Paymerir Action: Arnounf of Payment: Signature: Name (Type or Print): Date: 10. Recommended $20,000.00 t , � Michele Folk 414!2011 PrincipalNice President 11. Approved $20,000.00 Otrerland, Pacific & CNfer, lire. Page I of 2 =BC -us (4;04)