HUD-40056 Claim for Fixed Payment in Lieu of Payment for Actual No

Claim for Fixed Payment
in Lieu of Payment for Actual Nonresidential
Moving and Related Expenses

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

OMB Approval No. 2506-0016
(exp. 07/31/2008)

(49 CFR 24.305)
For Agency
Use Only

Name of Agency

Project Name or Number

Case Number

Instructions: This claim form is for the use of displaced businesses, nonprofit organizations, and farm operators that wish to claim a Fixed
Payment, rather than claim a Payment for Actual Reasonable Moving and Related Expenses, including Reestablishment Expenses
under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (URA). The minimum fixed payment is
$1,000; the maximum is $20,000. This payment is based on the average net annual earnings of an eligible business or farm operation
before income taxes during the 2 tax years prior to the tax year in which it was displaced (see 49 CFR 24.305(e)); or for a nonprofit organization, based on the average of 2 years gross annual revenues less administrative expenses for the two 12 month periods prior to the
acquisition (see 49 CFR 24.305(d)). The Agency will explain the difference between the two payments and will help you complete this
form. HUD provides information on these requirements and other guidance materials on its website at www.hud.gov/relocation. If you are
eligible for either payment, the Agency will help you to determine which is most advantageous. If the full amount of your claim is not
approved, the Agency will provide you with a written explanation of the reason. If you are not satisfied with the Agency’s determination, you
may appeal the determination. The Agency will explain how to make an appeal.
All claims for payments must be filed no later than 18 months from the date of displacement (see 24.207(d)).
Fixed Payment Eligiblity: 1. Business: (see 49 CFR 24.305(a)), 2. Nonprofit Organization: (see 49 CFR 24.305(d)) & 3. Farm
Operation: (see 49 CFR 24.305(c))
Section A. General
1. Name of Business, Farm or Nonprofit Organization

2. Name, Title, Address & Telephone Number of Claimant or
Claimant's Authorized Agent

3. Address from which Business, Farm or Nonprofit Organization Moved

4a. Date Move Started (mm/dd/yyyy)

4b. Date Move Completed (mm/dd/yyyy)

4c. Address to which Business, Farm or Nonprofit Organization Moved
(If Business, Farm or Nonprofit Organization went out of business, check here

5. Type of Operation (check one)
Business
Farm Operation
Nonprofit Organization

6. Type of Ownership
Sole Proprietorship
Partnership

)

Corporation
Nonprofit Organization

7. Is This a Final Claim?
Yes
No (If "No", attach
explanation)

Certification of Legal Residency in the United States (Please read instructions below before completing this section.)
Instructions: To qualify for relocation advisory services or relocation payments authorized by the Uniform Relocation Assistance and Real
Property Acquisition Policies Act, a “displaced person” must be a United States citizen or national, or an alien lawfully present in the United
States. The certification below must be completed in order to receive any relocation benefits. (This certification may not have any
standing with regard to applicable State laws providing relocation benefits.) Please address only the category that describes your citizenship status. For item (2), please fill in the correct number of partners. The certification for a nonresidential displaced person may be signed
by an owner or other person authorized to sign on its behalf.
Your signature on this claim form constitutes certification. See 49 CFR 24.208(g) & (h) for hardship exceptions.
NONRESIDENTIAL DISPLACEMENTS
(1) Sole Proprietorship.
(2) Partnership.
I certify that I am: (check one)
I certify that there are ______ partners in the
_____ a citizen or national of the United States partnership and that______ are citizens or
_____ an alien lawfully present in the
nationals of the United States and _____ are
United States.
aliens lawfully present in the United States.

Previous editions are obsolete

Page 1 of 3

(3) Corporation. (Name of Corporation)
I certify that ___________________,
is established pursuant to State law and is
authorized to conduct business in the
United States.

form HUD-40056 (04/2005)

Section B. Computation of Average Net
Earnings or Net Revenues for Base Period 1/

Item

Table I. Individual or Sole Proprietor (Relates to IRS Form 1040)

Base Period
Year (yyyy)

Year (yyyy)

For Agency Use Only

Average

$

$

$

$

$

$

$

$

$

$

$

$

(8) Net Earnings (Add lines (5), (6) and (7))

$

$

$

$

Table III. Partnership (Relates to IRS Form 1065)
(9) Ordinary Income (Or loss) Before
Taxes (From IRS Form 1065)

$

$

$

$

(12) Net Earnings (Add lines (9), (10), and (11))

$

$

$

$

Table IV. Nonprofit Organization
(13) Annual Gross Revenues 5/

$

$

$

$

$

$

$

$

(1) Net Profit (Or loss) Before Taxes from IRS Form 1040
2/

(2) Adjustments (Attach statement)

(3) Compensation Paid to Owner, Owner's Spouse, and
Dependents (List names and amounts to each on a
separate page)

(4) Net Earnings (Add lines (1), (2) and (3))
Table II. Corporation (Relates to IRS Form 1120 and 1120-S)
(5) Taxable Income from IRS Form 1120
(Or ordinary income from IRS Form 1120-S)
2/

(6) Adjustments (Attach statement)

(7) Compensation Paid to Principal Stockholders, their
Spouses, and Dependents (List names and amounts to 3/
each on a separate page)

(10) Adjustments (Attach statement)

2/

(11) Compensation Paid to Principal Partners, their
Spouses, and Dependents (List names and amounts to 4/
each on a separate page)

(14) Administrative Expenses 6/
(15) Net Revenues (Subtract line (14) from line (13))

1/ This is usually the two tax years prior to your displacement. Please
consult the Agency.
2/ To the extent that the profit/income entry in Section B, line (1), (5) or
(9) has been reduced by an expense that was not incurred in the base
period (e.g., a loss carry forward from a previous year, loss carry back
from a later year or declared depreciation in excess of actual depreciation) such expense must be added back on line (2), (6) or (10). To
the extent that the entry on line (1), (5) or (9) is inflated by an amount
not actually earned in the base period (e.g., refund of State or local
income taxes or income included under the tax benefit rule because
a deduction taken in a previous year was disallowed), it should be
entered on line (2), (6) or (10) as a subtraction.

3/ Principal stockholder is one who owns 15% or more of the
corporation.
4/ A principal partner is one with a proprietary interest of
15% or more in the concern.
5/ Gross revenues may include membership fees, class
fees, cash donations and other fund collections.
6/ Administrative expenses include rent, utilities, salaries
and fund raising costs.

Section C. Computation of Payment

Item
(1) Amount from line (4), (8), (12) or (15) of Section B (If less than $1,000, enter
$1,000. If more than $20,000, enter $20,000)

Amount Claimed

For Agency Use Only

$

$

$

$

(2) Amount Previously Received (if any)
(3) Amount Requested (Subtract line (2) from line (1))
Previous editions are obsolete

Page 2 of 3

form HUD-40056 (04/2005)

Section D. Certification By Claimant(s): I certify that the information on this claim form and supporting documentation is true and complete and that I
have not been paid for these expenses by any other source.
Signature(s) of Claimant(s) or Claimant's Authorized Agent

TItle (Type or Print)

Date

X
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
To Be Completed by Agency
Payment Action

Amount of Payment

2. Recommended

$

3. Approved

$

Signature

Name (Type or Print)

Date

Remarks

Public reporting burden for this collection of information is estimated to average 1.0 hours per response. This includes the time for collecting, reviewing,
and reporting the data. The information is being collected under the authority of the Uniform Relocation Assistance and Real Property Acquisition Policies
Act of 1970, and implementing regulations at 49 CFR Part 24 and will be used for determining whether you are eligible to receive a fixed moving payment
instead of a payment for actual moving and related expenses and the amount of any payment. Response to this request for information is required in order
to receive the benefits to be derived. This agency may not collect this information, and you are not required to complete this form unless it displays a
currently valid OMB control number.
There is no assurance of confidentiality. This form is for the use of displaced businesses, nonprofit organizations, and farm operators that wish to apply
for a Fixed Payment rather than a Payment for Actual Reasonable Moving and Related Expenses, including Reestablishment Expenses. (The Maximum
Fixed Payment is $20,000.) The Agency will explain the difference between the two types of payments. If you are eligible to choose either payment, the
Agency will help you to determine which is most advantageous. If the full amount of your claim is not approved, the Agency will provide you with a written
explanation of the reason. If you are not satisfied with the Agency’s determination, you may appeal the determination. The Agency will explain how to
make an appeal. This information is being collected under the authority of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of
1970. The information may be made available to a Federal Agency for review.
Previous editions are obsolete

Page 3 of 3

form HUD-40056 (04/2005)