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![](media/image1.wmf){width="0.35138888888888886in"
height="0.3451388888888889in"}

U.S. Department

of Transportation

**Federal Aviation**

**Administration**

**Claim for Relocation Payments - Residential**

(Uniform Relocation Assistance and Real Property Acquisition Policies
Act - 42 U.S.C 4601 et seq.))

This form is for use in applying for payment of moving costs;
homeowners\' replacement housing payment; rental replacement housing
payment and downpayment, and incidental expenses. A representative will
explain the differences between types of payments and, if you wish, will
help you complete the forms. No payments will be made unless the forms
are properly executed and received (42 U.S.C 4622). If your claim is
disapproved and/or adjusted from amounts claimed, you will be provided a
written explanation for the reason and steps that you may take to have
your claim reviewed, in accordance with regulations and procedures.

**Note:** receipts, vouchers, closing statements or other documentation
must support Actual expenses, or similar evidence remitted with the
appropriate forms.

**Privacy Act Statement:**

42 U.S.C. 4601 et seq. Authorizes collection of this information. The
primary use of the information is to determine whether the claimant is
eligible for and entitled to relocation benefits. Furnishing the
information is required in order to process your claim. Failure to do so
may result in nonpayment. The information may also be provided to
appropriate Federal, state, local, or foreign agencies responsible for
investigation or prosecuting a violation of law; to the Department of
Justice when relevant to litigation or anticipated litigation.

**Penalty for False or Fraudulent Statement:**

U.S.C. Title 18, 1001, provides: "Whoever, in any matter within the
jurisdiction of any department or agency of the United States knowingly
and willfully falsifies... or makes any false, fictitious or fraudulent
statements of representations, or makes or uses any false writing or
document knowing the same to contain any false, fictitious or
fraudulent, statement or entry, shall be fined not more than \$10,000 or
imprisoned not more than five years or both."

**You Must be Lawfully Present in the United States**

In accordance with the provisions of PL 105-117 amending the Uniform
Relocation Assistance and Real Property Acquisition Policies Act (42
U.S.C. 4601 et seq.), any person who is an alien not lawfully present in
the United States is ineligible for relocation advisory services and
relocation payments, unless such ineligibility would result in
exceptional and extremely unusual hardship to qualifying spouse, parent,
or child, as defined in 49 CFR 24.208(I).

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<table>
<colgroup>
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"><p><img src="media/image1.wmf"
style="width:0.35139in;height:0.34444in" /></p>
<p>U.S. Department of Transportation</p>
<p><strong>Federal Aviation Administration</strong></p></td>
<td colspan="7"><strong>Claim for Relocation Payments -
Residential</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="5">Acquiring Agency (Airport Sponsor):     </td>
<td colspan="9">Project/ Tract       /      </td>
<td colspan="3" rowspan="2"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5">Date of Initiation of Negotiations:      </td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="14"><strong>Section I - To be Completed by
Claimant</strong></td>
<td colspan="5"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="2"><p>1. Name:      </p>
<p>Address Acquired Dwelling:      </p>
<p>City:      </p>
<p>State:   Zip:     </p>
<p>Telephone #:      </p>
<p>Number of Rooms:     </p>
<p>(excluding, baths, hallway, closets, etc)</p></td>
<td colspan="11"><p>2. Did you occupy the agency acquired dwelling?</p>
<p> Yes If Yes; Permanent -or- Seasonal</p>
<p> No</p></td>
<td colspan="3" rowspan="2"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="11"><p>3. Were you a:</p>
<p> Owner Tenant Sleeping Room Occupant</p>
<p> Furnished rental (did not own furniture.)</p></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="3">4. Date you purchased/rented the Agency Acquired
dwelling:      </td>
<td colspan="11"><p>5. Date you moved from the Agency</p>
<p>Acquired dwelling:      </p></td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="14">6. If all members of the household have
<strong>NOT</strong> moved together, list their names, addresses,
relationship, and ages.</td>
<td></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td>Name</td>
<td colspan="6">Address</td>
<td colspan="5">Relationship</td>
<td colspan="2">Age</td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="6">     </td>
<td colspan="5">     </td>
<td colspan="2">   </td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="6">     </td>
<td colspan="5">     </td>
<td colspan="2">   </td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="6">     </td>
<td colspan="5">     </td>
<td colspan="2">   </td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="6">     </td>
<td colspan="5">     </td>
<td colspan="2">   </td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="6"><p>7. Address of Replacement Dwelling:</p>
<p>Street:      </p>
<p>City:       State:   </p>
<p>Zip:     </p></td>
<td colspan="8"><ol start="8" type="1">
<li><p>Date you purchased/rented</p>
<p>the replacement dwelling:     </p></li>
<li><p>Date you moved into the</p></li>
</ol>
<p>Replacement dwelling:      </p></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="8">10. Claim</td>
<td colspan="2"><strong>Amount</strong></td>
<td colspan="4"><p><strong>For Agency</strong></p>
<p><strong>Use Only</strong></p></td>
<td colspan="7" rowspan="5"></td>
</tr>
<tr class="even">
<td colspan="8">Moving Costs (<em>Attach Schedule A)</em></td>
<td colspan="2">     </td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="8">Replacement Housing Payment - 180-day Owner Occupant
<em>(Attach Schedule B)</em></td>
<td colspan="2">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="8">Replacement Housing Payment - 90-day Tenant/Owner
Occupant <em>(Attach Schedule C)</em></td>
<td colspan="2">     </td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="8">Down Payment and Incidental Expense <em>(Attach Schedule
D)</em></td>
<td colspan="2">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="14"><ol start="11" type="1">
<li><p><strong>Certification:</strong></p></li>
</ol>
<blockquote>
<p><strong>I CERTIFY under the penalties and provisions of U.S.C Title
18 and/or any other applicable law, that this claim and information
submitted herewith has been examined and is true, correct, and complete.
I have not submitted any other claim for, or received reimbursement or
compensation from any other source for any item of this claim; and that
any receipts submitted herewith accurately reflect costs actually
incurred. I certify that the choice of payment was made on the basis of
a full explanation by the displacing agency representative of the
differences between the types of payment available.</strong></p>
</blockquote></td>
<td colspan="6" rowspan="4"></td>
<td rowspan="2"></td>
</tr>
<tr class="odd">
<td colspan="14"><p><strong>As required by law (PL 105-117), in making
this claim and receiving payment I further CERTIFY:</strong></p>
<ul>
<li><p> <strong>I am either a citizen or national of the United States,
or an alien who is lawfully present in the United States; and as
applicable</strong></p></li>
<li><p> <strong>That each family member of the displaced household for
which I am making a claim, is either a citizen or national of the United
States, or an alien lawfully present in the United
States.</strong></p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4">Signature:</td>
<td colspan="10">Signature:</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">Date:</td>
<td colspan="10">Date:</td>
<td></td>
</tr>
<tr class="even">
<td colspan="14"></td>
<td colspan="7"></td>
</tr>
</tbody>
</table>

+--------------------------+----------------------+-------------------+
| **Section II - To Be     |                      | Project/ Tract    |
| Completed By Agency**    |                      |       /           |
|                          |                      |                   |
+--------------------------+----------------------+-------------------+
| **DSS INSPECTION AND     |                      |                   |
| CERTIFICATION**          |                      |                   |
|                          |                      |                   |
| **Displacee:             |                      |                   |
| Property Street Address: |                      |                   |
|      **                  |                      |                   |
|                          |                      |                   |
| Does the replacement     |                      |                   |
| dwelling conform to the  |                      |                   |
| following standards for  |                      |                   |
| Decent, Safe, and        |                      |                   |
| Sanitary Housing?        |                      |                   |
|                          |                      |                   |
| YES NO                   |                      |                   |
|                          |                      |                   |
| 1\. Conforms to local    |                      |                   |
| housing and occupancy    |                      |                   |
| codes?                   |                      |                   |
|                          |                      |                   |
| 2\. Structurally sound,  |                      |                   |
| weathertight, and in     |                      |                   |
| good repair?             |                      |                   |
|                          |                      |                   |
| 3\. Contains a heating   |                      |                   |
| system able to maintain  |                      |                   |
| 70ºF in living area?     |                      |                   |
|                          |                      |                   |
| 4\. Has an adequate,     |                      |                   |
| safe electrical wiring   |                      |                   |
| system?                  |                      |                   |
|                          |                      |                   |
| 5\. Has separate         |                      |                   |
| bathroom facilities that |                      |                   |
| conform to DSS           |                      |                   |
| standards?               |                      |                   |
|                          |                      |                   |
| (private, hot/cold water |                      |                   |
| to sink & shower/tub,    |                      |                   |
| sewer connection, flush  |                      |                   |
| water closet, all in     |                      |                   |
| working order)           |                      |                   |
|                          |                      |                   |
| 6\. Has a kitchen        |                      |                   |
| facility that conforms   |                      |                   |
| to DSS standards?        |                      |                   |
|                          |                      |                   |
| (hot/cold water to sink, |                      |                   |
| connected to sewer,      |                      |                   |
| range/refrig space &     |                      |                   |
| utility connection, all  |                      |                   |
| in working order)        |                      |                   |
|                          |                      |                   |
| 7\. Has adequate         |                      |                   |
| unobstructed egress?     |                      |                   |
|                          |                      |                   |
| 8\. Is property barrier  |                      |                   |
| free to accommodate      |                      |                   |
| disabled displaced       |                      |                   |
| person? Yes \* No N/A    |                      |                   |
|                          |                      |                   |
| \* If No, describe       |                      |                   |
| property improvements to |                      |                   |
| be made to provide       |                      |                   |
| barrier free ingress,    |                      |                   |
| egress, or use of        |                      |                   |
| property as required to  |                      |                   |
| accommodate disabled     |                      |                   |
| person(s) prior to       |                      |                   |
| occupancy.               |                      |                   |
|                          |                      |                   |
| \_\_\_\_\_\_\_\_         |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
|                          |                      |                   |
| **\*\                    |                      |                   |
| *\*\*\*\*\*\*\*\*\*\*\*\ |                      |                   |
| *\*CERTIFICATION\*\*\*\* |                      |                   |
| \*\*\*\*\*\*\*\*\*\*\*** |                      |                   |
|                          |                      |                   |
| TO THE BEST OF MY        |                      |                   |
| KNOWLEDGE, BASED ON      |                      |                   |
| VISUAL INSPECTION OF THE |                      |                   |
| PROPERTY, THE            |                      |                   |
| REPLACEMENT DWELLING     |                      |                   |
| MEETS THE STANDARDS FOR  |                      |                   |
| DECENT, SAFE, AND        |                      |                   |
| SANITARY HOUSING, AS     |                      |                   |
| ESTABLISHED IN THE       |                      |                   |
| RELOCATION ASSISTANCE    |                      |                   |
| PROCEDURES OF THE        |                      |                   |
| AIRPORT AUTHORITY AND    |                      |                   |
| CONFORMING TO 49 CFR     |                      |                   |
| PART 24 FOR FEDERALLY    |                      |                   |
| ASSISTED PROJECTS.       |                      |                   |
|                          |                      |                   |
| THE DWELLING DOES NOT    |                      |                   |
| PRESENTLY CONFORM TO DSS |                      |                   |
| REQUIREMENTS, BUT CAN BE |                      |                   |
| MADE TO CONFORM BY       |                      |                   |
| ACCOMPLISHING THE        |                      |                   |
| FOLLOWING PRIOR TO       |                      |                   |
| PURCHASE AND             |                      |                   |
| OC                       |                      |                   |
| CUPANCY.\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
|                          |                      |                   |
| \_\_\_\_\_               |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
| \_\_\_\_\_\_\_\_\_\_\_\_ |                      |                   |
|                          |                      |                   |
| THIS DETERMINATION IS    |                      |                   |
| MADE ON BEHALF OF THE    |                      |                   |
| AIRPORT AUTHORITY, AND   |                      |                   |
| IS MADE SOLELY FOR       |                      |                   |
| PURPOSES OF DETERMINING  |                      |                   |
| ELIGIBILITY FOR          |                      |                   |
| REPLACEMENT HOUSING      |                      |                   |
| PAYMENTS.                |                      |                   |
|                          |                      |                   |
| DATE:                    |                      |                   |
| INSPECTOR/AGENT:         |                      |                   |
|                          |                      |                   |
| Signature:               |                      |                   |
|                          |                      |                   |
| \*\*\*\*\*\*\*\*\*\*\*   |                      |                   |
| \*\*\*\*\*\*\*\*\*\*\*\* |                      |                   |
| \*\*\*\*\*\*\*\*\*\*\*\* |                      |                   |
+--------------------------+----------------------+-------------------+
| Remarks:                 |                      |                   |
+--------------------------+----------------------+-------------------+
| END - SAVE FORM          |                      |                   |
+--------------------------+----------------------+-------------------+