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9/3/2011 6:4? Remote ID Imprint ID ❑ 9/9
<br />Clitim for Actual Reasonable Moving ailild Related Elxpenses
<br />INSTRUCTIONS: Thfs "Ant for Is for the use of dlspreeed bustnessak noop m owntsatlaas, 4, ..g,.F
<br />'ri,�•t
<br />and 110011 operaft'o yet IWM 16 6Apry lot a PAYMENT FOR ACTUAL RCASONAeL6 MOVAYe +`' ! '. av� F ,t -'g °,3 r i4 'rrogliLS,b IiiF,`, tt �.s'�'r
<br />ANnRFF. Sr49LfSlfrdENTEXAGNSr: S, ralhw Mon appry fare FLYEO PAYMENT (Wme""'a Agency City of Santa Ana
<br />mhdm,nn of $1,000.00 and a mmlhwn) of $20,000.00J The Apepcy vAaxP*A Me d0amncea
<br />between rho Ave payments: If you are pf'pibfe to choose Whet pays K file Agwy Project Bristol Street Widening
<br />mprosa,d.viva win help you defeawne WaM he moil advanlepeow, and IWk hNp yov camppte
<br />tae lomr. It Ma lute Nnoun( at your arerm hint approved Ilia Agency will piovltll you IWfh a Case # 6TA-037 -00828 -200
<br />W60011 01119"nyon o/ Mn 166101 if yob are not sagsaed WA Ike Agency's deknWria$oA M
<br />MAY eApWthA ldef ennrna" The Agency wMaxpWahow to make it) appeal, T)W31 mason Program Rules OPC Claim SorialNumber
<br />Is being CoAded under On auMaity of Mo Ua burr Rmbcagbtl Asstafenco and Reef Properly
<br />ralclleesl�SANrURA)androi Cah'kmfo Reloaaeon ArtWonce Aat. Federal I X I State Other LG013269
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<br />+1?.. � T81 - .i..\ � .,'i.�l:t.•�k 4.V1�t.:Yfi �- Te. pav' 1�•, �{ Ji •1�t!'f�.,:L ?'.i {}CF�'f4,Y,?i:. �1�,:.. F�S �Msr..� .��:9Ys:. V. r...11frf.�. �t {Y' a�..!_�`z
<br />1. Name Under W11leh Claimant Conducts operations
<br />2. Name, Tltlo and Phone of Person FNlne Clalm on Behalf of Claimant
<br />Lin Dia A La Vez
<br />Luis Paredes, President 714 889 -8229
<br />ga. Address From Which Claimant Moved
<br />3b. Dale First Occupied
<br />3c. Date Move Started
<br />828 N. Bristol Street #200
<br />011/2000
<br />6/112011
<br />Santa Ana, CA 92703
<br />4a. Address 10 Which Claimant Moved
<br />4b. Dale Movo Comploted
<br />8. la This o Final Clain?
<br />1226 W. 17th Street Suite #2
<br />811(2011
<br />( X ] Yes [ ] No
<br />Santa Ana, CA 92706
<br />G. 'rype at Operation, (Check One):
<br />Y. Type of Ownership (Check One):
<br />( J 8usitess [ J Farm Operation [ x J Nonprofit Operation
<br />Sate Pro stet. Corporation [ I Partnership f x I Nonprofit Ore.
<br />8. Computation of Payment
<br />ITEM
<br />AMOUNT CLAIMS
<br />Ptft, AGEN U,9 DtlL'(
<br />M
<br />(1) Moving Expenses (from Section S)
<br />$21030.00
<br />(2) Reostabllshment Expenses ($10,000 maximum, from Section C)
<br />$10,000.00
<br />v
<br />(3) Reasonable Searching Expenses (Attach Schedule)
<br />$1,000.00
<br />(4) Storage Expenses (Attach Schedule)
<br />(5) Actual Direct Loss of Personal Property (Attach Schedule)
<br />(G) Other Expenses (attach explanation)
<br />(7) Total Amount Claimed (add lines (1) through (6))
<br />$13,030.00
<br />(8) Arnount Previously Received for Expenses Claimed Were (If any)
<br />$0,00
<br />(9) Offset amount for Rents Due to the Agency
<br />$2,866.75
<br />(10) Amount Requested (Line (7) minus Line (8))
<br />$10,174,26
<br />9. Certification by Claltnant(s)
<br />WAMIAIG: It you !glowingly ordofiboralely make 16130 statements on this 16`11l, you Wray be subject to W or crlmini0 penattles under Section 100f of TWO 18 011118
<br />United Steles code. to addition you may not recaive any of the emounts claimed on this farm. I CERTIFY that this claim end supporting Information are Imo and
<br />complele, that /hove not submdfed any other claim for the expenses psted and that I have not boon paid for the expanses by any other source: My choice of type of
<br />payment was made on Ilia basis of fun Olifenatlon by the dlsplecing Agency representative of the difference between the two types ofpsyments avopebla and the
<br />eligibibjy for each
<br />a s) of of" or`Clolmonga) Aeon) Tfaa $Type or Pant) pate
<br />40�
<br />uS EDALY
<br />^ 1ri35wt x
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<br />� fc i 1
<br />1NCY i
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<br />Payment Acflon
<br />Amount of Payment
<br />5j nature
<br />Name (Type or Print)ate
<br />10. Recommended
<br />$10,174,26
<br />t
<br />11. Approved
<br />$10,974.26
<br />@) Overland. Pnei le & Cutler. Jlte• Pa go 1 of 2
<br />�hC•01 (7ro4)
<br />25F -12
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