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Claim for Fixed Payment in Lieu of Actual Moving and Related Expenses <br />Business, Nonpro fit Organizations and Farm Operations <br />I FOR AGENCY USE ONLY <br />This claim is for the use of displaced fxuinesses, nonprofit <br />organisations, and from operations that wish to apply for a Fixed Payment in Lieu of <br />Actual Moving Expenses rather than apply for Actual Moving Expenses. The Agency: City of Santa Ana <br />minimum fixed payment is $1,000.00; the maximum fixed payment is S20,000.00. <br />The Agency will explain the differences between the two payments. If you are <br />eligible to choose either payment, the Agency representative will help you determine Project: Bristol Street Widening Project <br />which is most advantageous, and will help you complete the form. If the full amount <br />of your claim is not approved.. the Agency will provide you with a written explanation <br />of the reason. If you are not satisfied with the Agency's determination, you may <br />Case #: STA-036-01631-201 <br />appeal that determination. The Agency will explain how to make an appeal. This <br />information is being collected under the authority of the Uniform Relocation <br />Assistance and Real Property Policies Act (URA) and/or California Relocation Program Rules: OPC Claim Serial Number: <br />Assistance Act. <br /> [ ] Federal [X] State [ ] Other LG01275 <br />SECTION A: GENERAL <br />1. Name Under Which Claimant Conducts Operations: 2. Name, Title and Phone # of Person Filing Claim on Behalf of Claimant: <br />Livescan N More Michelle Smith, Owner - 7141568-1516 <br />3a. Address From Which Claimant Moved: 3b. Date First Occupied: 3c. Date Move Started: <br />1631 N. Bristol, Ste. 201, Santa Ana, CA 111/2008 Pending <br />4a. Address to Which Claimant Moved: 4b. Date Move Completed: 5. Is This a Final Claim? <br />Pending Pending [x] Yes [ ] No <br />6. Type of Operation (Check One): 7. Type of Ownership (Check One): <br />[x] Business [ ] Farm Operation [ ] Nonprofit Operation [ X ] Sole Propriet. [ ] Corporation [ ] Partnership [ ] Nonprofit Org. <br />8. Computation of Payment <br />ITEM AMOUNT CLAIMED FOR AGENCY USE ONLY <br />(1) Amount from Line (3), (6), (9) or (12) of Section E on reverse. <br />(if less than $1,000 enter $1,000, if more than $20,000 enter $20,000) $20,000.00 <br />(2) Amount Previously Received for Expenses Claimed Here (if any) <br />(3) Amount Requeted (Line (1) minus Line (2)) $20,000.00 <br />9. Certification by Claimant(s) <br />Warning: 11 you knowingly or deliberately make false statements on this form, you may be subject to civil or criminal penalties under Section 1001 of Title 111 or the United States Code <br />In <br />. <br />addition, you may not receive any of the amounts claimed on this form. I CERTIFY that this claim and supporting information are true and complete, that I have not submitted any other <br />claim for the expenses listed, and that I have not been paid for the expenses by any other source. My choice of type of payment was made on the basis of full explanation by the displacing <br />Agency representative the difference between the two types of payment available and the eligibility requirements for each. <br />Signature(s) of Claimant(s) or Claimant(s) Agent): Title (Type or Print): Date: <br /> 1 <br />FOR AGENCY USE ONLY <br />Payment Action: Amount of Payment. Signature: Name (Type or Priny: Date: <br />10. Recommended $20,000.00 IRA" Michele Folk/Principal 31912011 <br />11. Approved $20,000.00 <br />Overland Pacy1c & Cutler, Inc. <br />Page. 1 of') <br />25B-36 <br />=sC-05 (4/04)