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TP-25151R (2100) Minnesota Department of Transportation <br />RE-ESTABLISHMENT COSTS CLAIM <br />Fl Advance Claim Fl Partial Claim <br />Name (Payee) IBC Sales Corporation <br />Dist. Artemis GP. <br />C.S CID <br />Fed No. County <br />Prop. Owner BC Sales Corporation <br />PnopAddresy2404RiooS\neet <br />City/Sta$e/Zip Little Canada, W1N55113 <br />Type ofAcquisition: 0 Direct Purchase ED <br />Address 1213 Cliff Rd. E, Burnsville, MN <br />City/State/Zip 5130 Winnetka Ave., New Hope MN <br />gal Final Claim <br />Approved Amount $50,000.00 <br />Approved By <br />Approved By Jon W. Morphew <br />Relocation Manager <br />Date Appflcation Approved April 7 2011 <br />Moil Check to: <br />Name IBC Sales Corporation, CJO Barbara M. Ross <br />Address Best & Flanagan, LLP <br />225 South Sixth Street. Suite 4000 <br />City/State/Zip Minneapolis, MN 55402 <br />Vendor Number: <br />ELIGIBLE EXPENSES <br />A. Repairs or improvements as required by Iaw, code, or ordinance � <br />B. Modifications to accommodate tbe operation 3 <br />C. Exterior SFgning Q <br />D. UtiIities from RIW to the iniprovement � <br />E. Redecoration costs af worn surfaces � <br />F. Feasibility surveys, etc. � <br />G. Advertisement of Replacement Site � <br />H. Professional Services for purchase or lease af new site � <br />I. Est. increased costs of operation (leases, taxes, ins , utility charges during first 2 years) $ 50,000.00 <br />J. Other items - Licerises, fees, perrnits, etc (Approved by agency) � <br />K. TOTAL OF CLAIM (maximum $1U'0V0) $ 50,000.00 <br />Residency Certification: |attest, under penalty nf perjury, that that myself and/or niembers of this partnership, association or corporation are <br />lawfully citizens v[ United States or aliens lawfully admitted for residency and authorized to conduct business in the United States. <br />1, the undersigned, do hereby certify that the above information is true and correct, and that any receipts or statements attached hereto <br />accurateiy represent the expenses incurred. further certify that 1 have not subniitted any other claim for r&nibursement of, or received <br />compensation for, any expense in connection with this claim. I understand that falsification of any portion of this claim will result in its denial <br />MAIL CLAIM TO: <br />Date <br />Name (print) <br />Signature <br />Telephone <br />6 <br />