POMEROY, WILLIAM & GOCHICOA, AVELINO & STELLA -2005

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BUSINESS, FARM OR NONPROFIT ORGANIZATION CLAIM FOR ACTUAL REASONABLE MOVING EXPENSE (Cont.) Page 2 of2 Payment of this claim in the total amount shown in item #4 is requested. I CERTIFY that I have not submitted any other claim for, or received reimbursement or compensation fOf, any item of expense in this claim, from the City of Santa Ana Public Works Agency nor from any other public agency or private company, and that I will not accept reimbursement or compensation from any other source for any item of expense paid pursuant to this claim. I further certify that all information submitted herewith or included here is Ime and correct. I understand that only lawful U.S. residents are entitled to claim relocation benefits. I understand that, in addition to the penalty provided by Penal Code Section 72, falsification of any item in this claim as submitted herewith may result in forfeiture of the entire claim. (NOTE: Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city, district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claims, bill, account, voucher, or writing is guilty of a felony.") Date of Claim Claimant's Signature(s) ITEMS BELOW TO BE COMPLETED BY THE CITY OF SANTA ANA PUBLIC WORKS AGENCY I CERTIFY that I examined this claim and substantiation documentation and have found it to conform to the applicable provisions of State law and the California Code of Regulations, Title 25, HCD Guidelines (as amended). This claim is approved and payment in the total amount shown in item #4 is hereby authorized. Authorized Signature Date I ADA Notice For individuals with disabilities, this document is available in alternate formats. For information call (916) 654-5413 Voice, CRS: 1-800-735-2929, or write Right of Way, 1120 N Street, MS-37, Sacramento, CA 95814