Relocatee:	enter text	Project No.:	enter text
Address:	enter text	Designation:	enter text
enter text	Parcel No.:	enter text
Moved to:	enter text	Telephone No.:	enter text
enter text	Distance Moved:	enter text

☐ Business	☐ Farm or Ranch	☐ Non-profit Organization

Moving estimates by qualified mover (attach bid)	$enter amt
Actual moving expense by qualified mover (attach receipts)	$enter amt
Expenses related to searching (attach itemized receipts and explain)	$enter amt
TOTAL MOVING EXPENSE	$enter amt
STORAGE COSTS: (not to exceed 12 months, dates of storage Personal property stored (list separately on back side)
Storage costs (attach receipts)	$enter amt
TOTAL MOVING & STORAGE COSTS	$enter amt
Self-Move (attach bid)	Amount of lowest bid	$enter amt
TOTAL MOVING ALLOWANCE	$enter amt
Re-establishment costs (not to exceed $25,000) – list on back side	$enter amt
Fixed payment in lieu of payments for actual moving & related expenses and actual reasonable re-establishment expenses (not less than $1,000 or more than $40,000) Attach form 364	$enter amt

Choose a building block.