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form Approved OMB No.63-R1468 U.S.DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FOR AGENC USE ONLY CLAIM FOR ACTUAL MOVING COSTS AND ASE NUMBER PROJECT NAME OR NUMBER RELATED EXPENSES—BUSINESSES, NONPROFIT N/A St. Anthony Center ORGANIZATIONS,AND FARM OPERATIONS NAME AND ADDRESS OF AGENCY Include Zip Code HRA of St. Anthony (HUD Regulations at,24CFR Part 42) St. Anthony, Minnesota 55418 INSTRUCTIONS: This claim form is for use in applying for a relocation PAYMENT FOR ACTUAL MOVING AND RELATED EXPENSES of a business, non-profit organization, or farm operation. Before filing, the claimant should consult with the displacing agency to determine whether it would be to the claimant's advantage to apply for a FIXED PAYMENT in liru of a payment for actual moving and related expenses. A representative of the displacing agency will explain the differences between these two types of payments, and the eligibility requirements that apply. The representative will also describe the documentation that is needed in support of the claim. If the full amount of your claim is not approved, the displacing agency willprovide you with a written explanation of the reason. If you are not satisfied with the displacing agency's determination, you may appeal that determination. The displacing agency will explain how to make an appeal. A general description of reimbursable costs is contained on page 4 of this form. SECTION A — GENERAL DATA 1. NAME UNDER WHICH CLAIMANT CONDUCTS OPERATIONS 2. NAME,ADDRESS,AND TELEPHONE NUMBER OF PERSON FILING CLAIM ON BEHALF OF CLAIMANT Slicks Alternative Robert Slick 789-9497 3A. ADDRESS FROM WHICH CLAIMANT MOVED 3B.DATE FIRST OCCUPIED 3C.DATE MOVE STARTED 2533 Harding Street N. E. N/A January 1, ' 89 St. Anthony, MN 55418 4A. ADDRESS TO WHICH CLAIMANT MOVED 4B. DATE MOVE Apache Plaza COMPLETED St. Anthony, MN 55418 lianuary 7 , ' 89 5.TYPE OF OPERATION tCheck one 6.TYPE OF OWNERSHIP(Check one) 7. IS THIS A FINAL CLAIM? L Business ❑ Farm operation ❑ Sole proprietorship ® Corporation KI Yes ❑ No ❑ Nonprofit organization p ❑ Nonprofit (If"No,'"attach explanation) ❑ Partnership organization p 8. COMPUTATION OF PAYMENT ITEM AMOUNT FOR AGENCY CLAIMED USE ONLY (1) Moving Expenses (From Section B) $ 43 , 072 . 00 $4 3 , 0 7 2. 0 0 (2) Storage Costs(From Section C) 1, 500 . 00 1, 500. 00 (3) Reasonable Search Expenses(From Section D) 1, 000 . 00 1, 000. 00 (4) Actual Direct Loss of Personal.Property(From Section E) (5) Cost of Substitute Personal Property(From Section F) (6) Other(Attach explanation) Immovable Fixtures 9 , 026. 00 9, 026. 00 (7) TOTAL AMOUNT CLAIMED (Sure of Lines (1) thru (6)1 54 ,598 . 00 54 , 598. 00 (8) Amount Previously Received (If Any) None None (9) Amount Requested (Line(7)Minus Line (8)) $ $ 54 , 598 . 00 54 , 598 . 00 _ 9. CERTIFICATION BY CLAIMANT(S) WARNING: If you.knowingly or deliberately make false statements on this form,you may be subject to civil or criminal penalties under Section 1001 of TitlP- 18,of the United Stales Code. III -J.,lition you nlay not receive any of the amounts claimed on this form. I CERTIFY under the penalties and provisions of(!.S.C. Titre 18,Scr-tirns 286,287,and 1001,and any other applicable law, that this claim and information submitted have been examined by me and are true and cumplet:. I further certify I have not submitted any other claim for,or received compensation from .viy• other source for any item of this claim,and that any rr-reipts ruhmittec/with this claim accurately reflect costs incurred. A1y choice of type. r.f^3yrrenr was made on the basis of a.full explanation by the displacing au.:ncy representative of the differences between the two types of payments availabra and the eligibility requirements 'for each: (Signature(sl of C/aimant(sl or Claimant's Agent) (Name and Title (Type or Print) -70ate� 10. TO BE COMPLETED BY AGENCY PAYMENT AMOUNT OF ACTION PAYMENT SIGNATURE NAME(Type or Print) DATE Recommended S5.4 , 598 . 00 Jack Bagley 1/4/89 Approved 554 , 598 : 00 Dave Childs Previous Edition is Obsolete Page 1 HUD-4004(9.79)