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<br />EXHIBIT "A" Dr. Pomeoy, DDS "Business Self-Move Agreement" <br />~ CITY OF SANTA ANA PUBLIC WORKS AGENCY <br />BUSINESS, FARM OR NONPROFIT ORGANIZATION CLAIM <br />FOR ACTUAL REASONABLE MOVING EXPENSE <br />~ <br /> PERSONAL INFORMATION NOTICE <br /> Pursuant to the Federal Privacy Act (P.L.93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798, et.seq.), notice is hereby <br />given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary <br />information is to facilitate the processing of this form. The failure to provide all or any part of the requested infonnation may delay processing of this form. <br />No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right <br />upon request and proper identification, to inspect all personal information in any record maintained on the individual y\byan identifying particular. Direct <br />any inquiries on information maintenance to your IPA Officer. <br />ALL CLAIMS MUST BE FILED WITHIN 18 MONTHS AFTER: <br /> (a) For tenants, the date of displacement; or <br /> (b) For owners, the date of displacement or the date of the final payment for the acquisition of the real property, <br /> whichever is later. <br />CITY OF SANTA ANA Dist Co Rte KP(P.M.) Exp Auth <br />PUBLIC WORKS AGENCY <br /> AR <br /> Parcel No. <br /> Federal Project No. <br />1. FULL NAME OF CLAIMANT(S): Date of Move: <br />Dr. Pomeroy and A velino and Stella Gochicoa <br />2. DISPLACEMENT PROPERTY 3. REPLACEMENT PROPERTY <br />119 S. Bristol Street, Santa Ana, CA <br />4. ACTUAL REASONABLE MOVING AND RELATED EXPENSES BEING CLAIMED <br />The following items may be reimbursable as actual reasonable moving and related expenses. Documentation <br />in support of each claimed item is attached. <br /> Amount Claimed: <br />A. Packing, crating, disconnecting, dismantling, removing, transporting, <br /> Unpacking, uncrating, reassembly and reinstallation of personal property $ 18.230.00 <br />B. Utility and Service line reconnection $ <br />C. Telephone reconnection $ <br />D. Modification to personal property $ <br />E. Physical changes at new location $ <br />F. Storage $ <br />G. Insurance $ <br />H. License, permits and certification fees $ <br />I. Damaged, lost or stolen property $ <br />J. Professional services $ <br />K. Re-lettering & reprinting $ <br />L. Loss of tangible personal property $ <br />M. Resale costs $ <br />N. Substitute personal property $ <br />o. Search fees $ <br />P. Other moving expense payments, specify: $ 2.500.00 <br /> Total Amount Claimed $ 20.730.00 <br />