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9/3/2011 6:4? Remote ID Imprint ID ? 9/9
<br />INSTRUCTIONS: We "Ant lot is for the ass of dspleced Witnesses, naryxoAt ownt:atlaas,
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<br />10011 operaft Mil IWM to oA* lore PAYMENT FOR ACTUAL RCASONAeL6 MOVM +
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<br />ANr1RFF.SrAat(StfrdCNTExPENSr:S, n0hwMonapply fare FLYEOPAYMENT fWebhisa Agency City of Santa Ana
<br />m1tirmn or $1,000.00 and a maxMwn) of $20,000.00J The Apepay x90.lxpMA Me dlfamnces
<br />between Iho Ave payments, if you are olpfble ki choose Wet paynwll. the Agency Project Bristol Street Widening
<br />mpresonlarive win help you deterrrrtne WaM q moil advanlapeow, and W0 hNp you camplele
<br />The loint It Ma full amount of your orirm Is, not wmyod. Me Agency will pioK* you Ix4h a Case # 6TA-037-00828-200
<br />wi flea oxplannYon of Mn reesoa W you are not sapsaed wA Ike Agency's dolom9Aed A M
<br />meyoppoold+alOfennrna" The Agency wMaxpWnhow to make an appeal, Tllfsiftricaliea Program Rules OPC Claim Sartaf Number
<br />Is keiv collided under flu auModly of Mo Ua burr Rmbcagorl Asdifenco and Reif Properly
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<br />1. Name Under Witch Claimant Conducts operations 2. Noma, Tltlo and Phone of Person FNing Clalm on Behalf of Claimant
<br />Lin Dia A La Vez Luis Paredes, President 714 889-8229
<br />3a. Address From Which Claimant Moved 3b. Dale First Occupied 3c. Date Move Started
<br />828 N. Bristol Street #200 01112000 61112011
<br />Santa Ana, CA 92703
<br />4a. Address to Which Claimant Moved 4b. Dale Movo Comploted 1. la This o Final Clain?
<br />1226 W. 17th Street Suite #2
<br /> 811(2411 ( X ] Yes [ ] No
<br />Santa Ana, CA 92706
<br />8. 'rype of Operation (Check One): Y. Type of Ownership (Check One):
<br />( J 8usitess [ J Farm Operation [ x J Nonprofit Operation Sate Pro stet. Corporation [ J Partnership [ x I Nonprofit Ore.
<br />8. Computation of Payment
<br />ITEM AMOUNT CLAIMS Pelt, AGEN U,9 Df4L? ,
<br />(1) Moving Expenses (from Section s) $21030.00
<br />(2) Reostabllshment Expenses ($10,000 maximum, from Section C)
<br />$10,000.00 v
<br />(3) Reasonable Searching Expenses (Attach Schedule)
<br /> $1,000.00
<br />(4) Storage Expenses (Attach Schedule)
<br />(5) Actual Direct Loss of Personal Property (Attach Schedule)
<br />(G) Other Expenses (attach explanation)
<br />(7) Total Amount Clairned (add lines (1) through (6))
<br /> $13,030.00
<br />(8) Arnount Previously Received for Expenses Claimed Were (If any) $0,00
<br />(9) Offset amount for Rents Due to the Agency
<br /> $2,866.75
<br />(10) Amount Requested (Line (7) minus Line (8)) $10,174,26
<br />9. Certification by Claltnant(s)
<br />WAMIAIG: It you knoWngly ordofiboralely make false sfete/nents on this form, you maybe subiw to W or crlmloW pensWas under Section 100f of TWO 10 011118
<br />United Slates (.'ode. to addition you may not receive any of the emounts claimed on this form. I CERTIFY that this claim end supporting hlformalion are Into and
<br />complete, that /hove not submdled any other claim for the expenses paled and the! I have not boon paid for the expanses by any other source, A9y choice of type of
<br />paymnnt was made on Ilia basis of fuu oxpfanatlon by the dlsplacing Agency reptesenialive of the difference befwaan the hvo types ofpsymenls avopebla and the
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<br />Payment Acfion Amount of Pa menu i 4i natura Name (T o or print ale
<br />10. Recommended $10,174,26
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<br />11. Approved $10,174.26
<br />@) Overland, Poci rC & Cutler. 1t1C, Paton I of?.
<br />?hC•01 (7ro4)
<br />25F-12
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