POMEROY, WILLIAM & GOCHICOA, AVELINO & STELLA -2005

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" .' 'BtJSINESS, FARM, OR NONPROFIT ORGANIZATION CLAIM FOR REESTABLISHMENT EXPENSES (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 for, any item of expense in this claim, from the City of Santa Ana 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 herein is true 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 the 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.") ANY AMOUNTS paid pursuant to this claim shall not be duplicated in any compensation otherwise paid to or awarded to the owner of the business being relocated. Any or all amounts paid hereunder may be deducted from any payment paid, or to be paid by the State pursuant to Section 1263.510, Code of Civil Procedure (Compensation for Loss of Goodwill). Date of Claim Claimant's Signature(s) ITEMS BELOW TO BE COMPLETED BY THE CITY OF SANTA ANA 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 Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, (as amended). This claim is approved and payment in the total amount shown in item #4 is hereby authorized. Authorized Signature Date 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.