POMEROY, WILLIAM & GOCHICOA, AVELINO & STELLA -2005

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EXHIBIT "A" to Dr. Pomeroy, DDS "Business Self-Move Agreement" BUSINESS, FARM, OR NONPROFIT ORGANIZATION CLAIM FOR REESTABLISHMENT EXPENSES Page 1 of2 PERSONAL lNFORMA TION NOTICE 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 given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IP A of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on infonnation maintenance to your IPA Officer. ALL CLAIMS MUST BE FILED WITHIN 18 MONTHS AFTER: (a) For tenants, the date of displacement; or (b) For owners, the date of displacement or the date ofthe final payment for the acquisition of the real property, whichever is later. City of Santa Ana Public Works Agency Dist Co Rte KP(P.M.) Exp Auth 20 Civic Center Plaza M-36 Post Office Box] 988 Santa Ana, CA 92702 AR Parcel No. Federal Project No. I. FULL NAME OF CLAIMANT(S): Date of Move: Dr. William Pomeroy and A velino and Stella Gochicoa 2. DlSPLACEMENTPROPERTY 3. REPLACEMENT PROPERTY 119 S. Bristol Street, Santa Ana 4. REESTABLISHMENT EXPENSES BEING CLAIMED The following items may be reimbursable as reestablishment expenses. The total amount claimed cannot exceed $10,000. Documentation in support of each claimed item is attached. They are: A. Repairs or improvements required by law, code or ordinance. B. Modifications to accommodate the business operation. C. Exterior signing to advertise the business. D. Extending utilities from right of way line to improvements. E. Redecoration or replacement of soiled or worn surfaces. F. Licenses, fees and permits not paid as moving expenses. G. Feasibility surveys, soil testing and marketing studies. H. Advertisement of replacement location. 1. Professional services for purchase/lease of replacement. J. Estimated increased costs of operation during the first two years at the replacement site for lease or rental charges, taxes, insurance, and/or utility charges (excluding impact fees). K. Impact fees or one-time assessments for anticipated heavy utility usage. L. Other items considered essential for reestablishment, specify: Amount Claimed: $ $ $ $ $ $ $ $ $ $ $ $ 10.000.00 Total Amount Claimed $ 10.000.00