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Minnesota Department of Transportation <br />APPRAISAL FEES REIMBURSEMENT CLAIM <br />I Advance Claim _' Partial Claim Final Claim <br />FOR OFFICIAL USE ONLY <br />Payeee: Village of Little Canada <br />District: Metro Artemis S.P.:6280 -304 Parcel: 331B <br />CS: 6280(35E =390) 906 C.ID.: T54972 <br />Fed. # County: RAMSEY <br />Owner: Village of Little Canada <br />Address: 3100 Country Drive <br />City Little Canda MN 55117 <br />TAX ID NUMBERS <br />Fed Tax ID /SS Numbe <br />State Tax ID Number: <br />FOR OFFICIAL USE ONLY <br />Approved Amount: <br />Approved by: <br />Date Application Approved: <br />Mail Check to: <br />FOR OFFICIAL USE ONLY <br />Vendor Number: <br />NAME AND ADDRESS OF QUALIFIED APPRAISER <br />Name of Appraiser: <br />Address: City: <br />MN License #: <br />State: Zip: <br />I, the undersigned, do hereby certify that the above infornmtion is true and correct, and that any receipts or statements attached <br />hereto accurately represent the expenses incurred. I further certify that I have not submitted any other claim for reimbursement <br />of, or have received compensation or reimbursement for, any expense in connection with this claim. I understand that any <br />falsification of any portion of this claim will result in its denial. <br />MAIL CLAIM TO: <br />James Correll ( L »sz (`& <br />Real Estate Rep <br />Comment: <br />Date: <br />Name (print): <br />Signature: <br />Telephone: <br />