RODRIGUEZ, XAVIER DBA CENTRO NATURAL DE SALUD - 2011

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Claim for Fixed Payment in Lieu of Actual Moving and Related Expenses Business, Nonprofit Organizations and Farm Operations INSTRUCTIONS: This claim is For the use of displaced businesses, mm�pmfit - AGIIE'N,CY USE ONLY, organizations, and from operations that wish to apply for a Fixed Payment in Lieu of Actual Moving Expenses rather than apply for Actual Moving Expenses. The Agency: City of Santa Ana minimum fixed payment is $l 000.00, the maximum fixed payment is $20,000.00. The Agency will explain the differences between the two payments. l ry.0 are eligible to choose either payment, the Agency representative will help you determine Project: Bristol Street Widening Project which is most advantageous, and will help ta g pyou complete the form. Ifthe fullamoum of your claim is not approved, the Agency will provide you with a written explanation ofthererson. If you are not satisfied with the Agency's determination, you may Case#: STA-037-00828-101 appeal that determination. The Agency will explain how to make an appeal. This information is being collected] under the authority of the Uniform Relocation Assistance and Real Property Policies Act(URA) and/or California Relocation Program Rules: OPC Claim Serial Number: Assistance Act. [ ] Federal [X] State [ ] Other LGO13182 SECTION A: GENERAL 1. Name Under Which Claimant Conducts Operations: 2. Name, Title and Phone # of Person Filing Claim on Behalf of Claimant: Centro Natural de Salud Xavier Rodriguez, Owner (714) 910-5632 3a. Address From Which Claimant Moved: 3b. Date First Occupied: 3c. Date Move Started: 828 N. Bristol Suite #101, Santa Ana 92703 1/1/1998 12/1/2010 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): [x] Business [ ] Farm Operation [ ] Nonprofit Operation [x] Sole Propriet. [ ] Corporation [ ] Partnership [ ] 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) $13,137.50 (2) Amount Previously Received for Expenses Claimed Here (if any) (3) Amount Requeted (Line (1) minus Line (2)) $13,137.50 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 1• of the United stales Goa.. 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 other 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 payment available and the eligibility requirements for each. Signature(s) of Claimant(s) or CI (s) A enq: Title (Type or Print): Date: FOR AGENCY USE kINLY Payment Action: Amount of Payment: Signature: Name (Type or Print): Date: 10. Recommended $13,137.50 C,. Michele Folk it v Principal/Vice President 7t ,5 11. Approved Overland, Pacific & Cutler, Inc. Page I of 2 =BC-05 (4/04)