Form DI-381 Claim for Relocation Payments - Residenntial

DEPARTMENT OF THE INTERIOR

OMB CONTROL NO.

CLAIM FOR RELOCATION PAYMENTS – RESIDENTIAL
(Public Law 91-646, as amended)

AGENCY:

1084-0010
Expires

PROJECT / TRACT:
ADDRESS:

DATE OF INITIATION OF NEGOTIATIONS:

SECTION I – TO BE COMPLETED BY CLAIMANT
INSTRUCTIONS: This form is for use in applying for payment of moving costs (42 USC 4622); homeowners replacement housing payment; rental
replacement housing payment and down payment and incidental expenses. The representative will explain the differences between types of payments and, if you wish, will help you complete the forms. No payments will be made unless the forms are properly executed and received. If your
claim is disapproved and/or adjusted from amounts claimed, you will be provided a written explanation for the reason and steps that you may take to
have your claim reviewed, in accordance with regulations and procedures. NOTE: Actual expenses must be supported by receipts, vouchers, closing
statements, or other documentation, or similar evidence remitted with the appropriate form.
1. NAME:
MAILING ADDRESS:
SOCIAL SECURITY NUMBER:
TELEPHONE NUMBER: (

)

Please address only the category (individual or family) that describes your occupancy status. For item (2), please fil in the correct number of
persons. (49CFR24.208(a)) Your signature on this claim form constitutes certification
(1) Individual – I certify that I am: (check one) ____ a citizen or national of the United States; ____ an alien lawfully present in the United States.
(2) Family – I certify that there are ____ persons in my household and that ____ are citizens or nationals of the United States and
____ are aliens lawfully present in the United States.

2. DID YOU OCCUPY THE AGENCY ACQUIRED DWELLING?
3. WERE YOU A:

HOMEOWNER OCCUPANT ❏

IF YES; PERMANENT ❏

OR: TENANT ❏

OR SEASONAL ❏

OR: SLEEPING ROOM TENANT ❏

4. DATE YOU PURCHASED THE AGENCY ACQUIRED DWELLING:
5. DATE YOU RENTED THE AGENCY ACQUIRED DWELLING:
6. DATE YOU MOVED INTO THE AGENCY ACQUIRED DWELLING:
7. DATE YOU MOVED FROM THE AGENCY ACQUIRED DWELLING:
8. WAS IT FURNISHED WITH YOUR OWN FURNITURE?
9. NUMBER OF ROOMS: (exclude bathrooms, closets, hallways)
10. LIST ALL MEMBERS OF THE HOUSEHOLD BY NAME, GENDER, RELATIONSHIP, AGE, AND DISABILITY IF ANY:

11. ADDRESS OF REPLACEMENT DWELLING: (To which you moved)

12. DATE YOU PURCHASED THE REPLACEMENT DWELLING:
13. DATE YOU RENTED THE REPLACEMENT DWELLING:
14. DATE YOU MOVED INTO THE REPLACEMENT DWELLING:
DI-381 1
(04/15)

15. CLAIM

AMOUNT

MOVING COSTS (Attach completed Schedule A)

FOR AGENCY USE ONLY

$_ _______________________

$_______________________________

$_ _______________________

$_______________________________

$_ _______________________

$_______________________________

$_ _______________________

$_______________________________

REPLACEMENT HOUSING PAYMENT; HOMEOWNERS
(Attach completed schedule B)
RENTAL REPLACEMENT HOUSING PAYMENT
(Attach completed Schedule C)
DOWN PAYMENT AND INCIDENTAL EXPENSES
(Attach completed Schedule D)

16. CERTIFICATION: I (We) CERTIFY under the penalties and provisions of U.S.C. Title 18, Sections 286, 287, 1001, and any other applicable law,
that this claim and information submitted herewith have been examined by me (us) and are true, correct, and complete. I (We) further certify that
I (We) have not submitted any other claim for, or received reimbursement or compensation from any other source for any item of this claim; and
that any receipts submitted herewith accurately reflect costs actually incurred. I (We) further certify that my (our) choice of type of payment was
made on the basis of a full explanation by the displacing agency representative of the differences between the types of payments available.
SIGNATURE:___________________________________________

SIGNATURE: ____________________________________________

DATE:_ _______________________________________________

DATE:___________________________________________________

PRIVACY ACT STATEMENT: 42 U.S.C. 4601 et seq. authorizes collection of this information. The primary use of the information is to determine
whether the claimant is eligible for and entitled to relocation benefits. Furnishing the information is required in order to process your claim. The
information may also be provided to appropriate Federal, State, local or foreign agencies responsible for investigating or prosecuting a violation
of law; to the Department of Justice when relevant to litigation or anticipated litigation.
PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et. seq.) requires the public to be
informed that this Information is being collected in order to assess claims for relocation expenses. Completion of this form, including gathering
of needed information, is estimated to take 50 minutes. Public comments on this estimate or suggestions for reducing this information
collection burden should be directed to the Office of Acquisition and Property Management, U.S. Department of the Interior, MS 4262-MIB,
Washington DC 20240. Submission of this form is necessary to obtain a government benefit. A federal agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
PENALTY FOR FALSE OR FRAUDULENT STATEMENT: U.S.C. Title 18, 1001, provides: ‘Whoever, in any matter within the jurisdiction of any
department or agency of the United States knowingly and willfully falsifies… or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be
fined not more than $10,000 or imprisoned not more than five years or bot

SECTION II – TO BE COMPLETED BY AGENCY
CERTIFICATION BY DISPLACING AGENCY: l certify that the above named claimant’s replacement dwelling located at
_ _________________________ in the County of __________________________________ and State of_________________________ was
inspected on_ _______________________ by __________________________________ _and was determined to be decent, safe, and sanitary.

SIGNATURE

INSPECTING OFFICIAL’S NAME AND TITLE

REMARKS:

DI-381 2

SCHEDULE A
PAYMENT OF MOVING COSTS – RESIDENTIAL
(Under Sec. 202, P.L.91-646, as amended )

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

2. PROJECT/TRACT:

3. TYPE OF
PAYMENT
CLAIMED:

FIXED PAYMENT

❏

REIMBURSEMENT FOR ACTUAL EXPENSE
(Complete item 4 including storage costs if applicable)

SUPPLEMENTARY CLAIM FOR
REIMBURSEMENT OF STORAGE
COSTS (Complete item 5)

❏

$ ____________

❏

4. ACTUAL MOVING EXPENSES (Supported by receipted bills for labor and equipment.)
(See reverse for allowable/nonallowable)
ITEM

AMOUNT CLAIMED

FOR AGENCY USE ONLY

MOVING COST

$ _________________

$__________________________

TRANSPORTATION COSTS-FAMILIES AND INDIVIDUALS (if any)

$ _________________

$__________________________

COST OF INSURANCE COVERING MOVE AND/OR STORAGE

$ _________________

$__________________________

STORAGE COSTS (Complete item 5)

$ _________________

$__________________________

OTHER (Explain on reverse under remarks)

$ _________________

$__________________________

TOTAL AMOUNT OF CLAIM

0.00
$ _________________

0.00
$__________________________

AMOUNT OF ADVANCE PAYMENT(S) RECEIVED (If any)

$ _________________

$__________________________

TOTAL AMOUNT (less advance, if any)

0.00
$ _________________

0.00
$__________________________

5. CLAIM FOR STORAGE COSTS: (Complete only if personal property was moved to or from storage)
TYPE OF CLAIM:

INITIAL

❑

STORAGE PERIOD: NUMBER OF
MONTHS ______
STORAGE COSTS:

SUPPLEMENTARY

❑

FINAL

ARE THE NUMBER
OF MONTHS
ACTUAL ❑

TOTAL COST INCURRED
$ ______________________

–$

OR:

❑

DATE PROPERTY WAS MOVED:
TO STORAGE: _______________
FROM STORAGE: ____________

ESTIMATED ❑

AMOUNT PREVIOUSLY RECEIVED

TOTAL AMOUNT

______________________

0.00
$ ______________________

=

6. METHOD OF PAYMENT: (Check one)
________

l (We) request the fixed payment.

________

I (We) have paid the moving costs itemized above and, therefore, request reimbursement.

________

I (We) have not paid the moving costs itemized above and, therefore, request payment be made directly to the mover and/or storage
company or other contractors, in accordance with arrangements made in advance, and with my (our) consent, between the agency
and the mover and/or storage company or other contractors.

________

I (We) hereby request and authorize the moving costs to be incurred, be paid directly to the mover and/or storage company or other
contractors, in accordance with arrangements made at this time, and with my (our) consent, between the agency and the mover
and/or storage company or other contractors.

7.
SIGNATURE: _________________________________________
DATE: __________________________

SIGNATURE: __________________________________________
DATE: _____________________________
DI-381 3

SECTION II – TO BE COMPLETED BY AGENCY
MOVING EXPENSE:

$

ADVANCE RECEIVED:

$

TOTAL AMOUNT:

$

0.00

PAYMENT AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

_____________________

_____________________________

__________________

________________

APPROVED:

_____________________

_____________________________

__________________

________________

FBMS INVOICE NO.:

_____________________

REMARKS:

ALLOWABLE MOVING EXPENSES
1.

Transportation of individuals, families, and personal property from
the acquired site to the replacement site not to exceed 50 miles,
except where the displacing agency determines that relocation
beyond this 50 mile area is justified.

7.

The reasonable cost of disassembling, moving, and reassembling
any appurtenances attached to a mobile home, such as porches,
decks, skirting, and awnings, which were not acquired, anchoring
of the unit, and utility ‘‘hookup’’ charges.

2.

Packing and unpacking, crating and uncrating of personal property.

8.

3.

Disconnecting, dismantling, removing, reassembling, and
reinstalling relocated household appliances, and other personal
property.

The reasonable cost of repairs and/or modifications so that a
mobile home can be moved and/or made decent, safe, and
sanitary.

9.

The cost of a nonrefundable mobile home park entrance fee, to
the extent it does not exceed the fee at a comparable mobile
home park, if the person is displaced from a mobile home park
or it is determined that payment of the fee is necessary to effect
relocation.

4.

Storage of personal property for a period not to exceed 12 months,
unless the agency determines that a longer period is necessary.

5.

Insurance for the replacement value of the property in connection
with the move and necessary storage.

6.

The replacement value of property lost, stolen, or damaged in
the process of moving (not through the fault or negligence of the
displaced person, his or her agent, or employee) where insurance
covering such loss, theft or damage is not reasonably available.

10. Other moving-related expenses that are not listed as ineligible
under Nonallowable Moving Expenses, as the Agency determines
to be reasonable and necessary.

NONALLOWABLE MOVING EXPENSES
1.

Cost of moving structures or other real property improvements in
which the displaced person reserved ownership.

2.

Interest on loan to cover moving expenses.

3.

Additional expenses incurred because of living in a new location.

4.

Personal injury.

5.

Any legal fee or other cost for preparing a claim for relocation
payment or for representing the claimant before the agency.

6.

Expenses for searching for a replacement dwelling.

7.

Physical changes to the real property at the replacement location.

8.

Costs for storage of personal property on real property already
owned or leased by the displaced person.

9.

Refundable security and utility deposits.

DI-381 4

SCHEDULE B
CLAIM OF HOME OWNERS REPLACEMENT HOUSING PAYMENTS – RESIDENTIAL
(Under Sec. 204 (a), P.L.91-646, as amended)

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

2. PROJECT/TRACT:

3. At the time you received the Agency's written offer to acquire your dwelling, was this dwelling owned and occupied by you for 90 consecutive
immediately prior thereto as your permanent residence?
YES ❏
NO ❏
4. INCIDENTAL EXPENSES: (Attach a copy of the closing statement and/or other documentation in support of the amounts claimed (49CFR24.401(e))
ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

LEGAL, Closing, and
Related COSTS

$ ___________

__________

TITLE SEARCH FEE

$ ___________

__________

NOTARY FEE

$ ___________

__________

RECORDING FEES

$ ___________ __________

SURVEY COSTS

$ ___________ __________

LENDER’S APPRAISAL FEE

$ ___________

__________

LENDER’S APPLICATION FEE

$ ___________

__________

CREDIT REPORT FEE

$ ___________

__________

Ow ner’s and MortGagee’s
Evidence of Title

$ ___________

__________

ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

ESCROW FEE

$ ___________

_ __________

TRANSFER TAXES

$ ___________

_ __________

LOAN ORIGINATION OR
ASSUMPTION FEES (that do not
represent prepaid interest)
$ ___________

_ __________

CERTIFICATION FEE

$ _ __________

_ __________

Home Inspection FEE

$ _ __________

_ __________

Termite Inspection FEE

$ _ __________

_ __________

OTHER (list) .......................

$ ___________

_ __________

.............................................

$ ___________

_ __________

.............................................

$ ___________

_ __________

TOTAL ......

0.00
$ ___________

0.00
_ __________

5. AMOUNT OF RENTAL ASSISTANCE PAYMENT PREVIOUSLY RECEIVED (If any) $ ______________________
6. AMOUNT OF REPLACEMENT HOUSING PAYMENT ADVANCED (if any)

$ _ ____________________________

SIGNATURE: _________________________________________________

SIGNATURE: ______________________________________
DATE: _______________

DATE: _______________

SECTION II – TO BE COMPLETED BY AGENCY
COMPUTATION OF AMOUNT OF PAYMENT
LAST RESORT HOUSING PAYMENT

YES ❏

PRICE OF A COMPARABLE DWELLING:

$ ________________

NO ❏

PRICE PAID FOR REPLACEMENT DWELLING: $ _______________
PRICE PAID FOR ACQUIRED DWELLING:
PAYMENT: (The lesser of the difference
between the comparable and acquired OR
the replacement and acquired dwelling)

$ ________________

0.00
$ ________________

MORTGAGE INTEREST COST: (See note)

$ _________________

AMOUNT OF INCIDENTAL EXPENSES

$ _________________

TOTAL PAYMENT:

0.00
$ _________________

AMOUNTS PREVIOUSLY PAID OR
ADVANCED:

$ _________________

TOTAL DUE UNDER THIS CLAIM:

0.00
$ _________________

Note: Increased mortgage interest costs can be claimed only if there was a bona fid mortgage(s) on the acquired dwelling for at least
immediately prior to the initiation of negotiations to acquire the property.

days

DI-381 5

COMPUTATION OF INCREASED MORTAGE INTEREST COSTS
AGENCY ACQUIRED DWELLING MORTAGE(S)
(a)

ITEM

FIRST

SECOND

REPLACEMENT
DWELLING
MORTAGE

THIRD

(b)

1. ISSUANCE DATE OF MORTGAGE
2. OUTSTANDING MORTGAGE BALANCE

$

$

$

$

3. AMOUNT OF MONTHLY MORTGAGE PAYMENT

$

$

$

$

4. ANNUAL INTEREST RATE OF MORTGAGE

%

%

%

$

0.00 $

0.00

$

$

$

0.00 $

%

5. MONTHS REMAINING ON MORTGAGE BALANCE: ...............
6. MONTHLY PAYMENTS OF:..(Iine 3) ...........................................

$

0.00

at the current prevailing fixed interest rate

7. FOR NUMBER OF MONTHS ... (line 5) ......................................
8. WILL PAY OFF A BALANCE OF:.................................................

$

9. INTEREST DIFFERENTIAL PAYMENT FOR
EACH MORTGAGE: ...................................................................
(line 2 minus line 8)

$

0.00

10. SUM OF PAYMENTS TO EACH MORTGAGE: .....................................
(from line 9, but not less than 0)

$ ______________

11. COST OF POINTS FOR MORTGAGE: ..................................................

$ ______________

12. TOTAL: .................................................................................................

$ ______________

0.00

13. IF line 2(b) IS LESS THAN THE TOTAL OF line 8 THEN:
_________
line 2(b)

-

_____________
total of line 8

=

______________
factor

x

___________ =
line 12

___________
total

REMARKS:

PAYMENT

AMOUNT

SIGNATURE

TITLE

RECOMMENDED:

_________________

________________________________________

__________________

APPROVED:

_________________

________________________________________

__________________

FBMS INVOICE NO.:

_________________

DATE

___________

___________

DI-381 6

SCHEDULE C
CLAIM OF RENTAL REPLACEMENT HOUSING PAYMENTS – RESIDENTIAL
(Under Sec. 204 (a), P.L.91-646, as amended)

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

2. PROJECT/TRACT:

3. WHAT WAS THE MONTHLY RENTAL RATE
OF THE DWELLING YOU VACATED?
$__________________

4. CHECK THE UTILITIES THAT WERE INCLUDED IN YOUR RENT:
❏ ELECTRIC
❏ GAS
❏ WATER
❏ OTHER

5. What is your average household monthly income? $ _________________
(Does not include income received or earned by dependent children and full time students under 18 years of age.) (49CFR24.2(a)(14))
6. WHAT IS THE MONTHLY RENTAL RATE FOR THE
REPLACEMENT DWELLING?
$__________________
8. REQUEST FOR PAYMENT:

9. SIGNATURE:

7. CHECK THE UTILITIES THAT ARE INCLUDED IN YOUR RENT:
❏ ELECTRIC

LUMP SUM

INSTALLMENT

❏

❏

________________________________________

❏ GAS

❏ WATER

FREQUENCY

AMOUNT OF INSTALLMENT

_ __________________
SIGNATURE:

DATE: ______________

❏ OTHER

$ _ ______________________

________________________________________

DATE: ______________

SECTION II – TO BE COMPLETED BY AGENCY
COMPUTATION OF AMOUNT OF PAYMENT
LAST RESORT HOUSING PAYMENT

YES ❏

BASE MONTHLY RENTAL OF COMPARABLE REPLACEMENT DWELLING:

$________________________

BASE MONTHLY RENTAL RATE OF REPLACEMENT DWELLING:

$________________________

BASE MONTHLY RENTAL RATE OF ACQUIRED DWELLING:
(actual rent or 30% of line 5, whichever is less) (49CFR24.402(b)(2)(ii))

$________________________

REPLACEMENT RENTAL COSTS:
(The lesser of the difference between the comparable
and acquired OR the replacement and acquired)

$________________________

AMOUNT DUE UNDER THIS CLAIM:
(Replacement rental costs multiplied by 42)

$________________________

AMOUNT

NO ❏

SIGNATURE

TITLE

DATE

RECOMMENDED:

_________________

_________________________________________

___________________

____________

APPROVED:

_________________

_________________________________________

___________________

____________

FBMS INVOICE NO.:

_________________

REMARKS:

DI-381 7

SCHEDULE D
DOWNPAYMENT AND INCIDENTAL EXPENSES – RESIDENTIAL
(Under Sec. 204 (b) P.L. 91-646, as amended)

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

2. PROJECT/TRACT:

3. PRICE PAID FOR REPLACEMENT DWELLING:

$ __________________

4. DOWNPAYMENT ACTUALLY PAID FOR REPLACEMENT DWELLING:

$ __________________

5. INCIDENTAL EXPENSES: (Attach a copy of the closing statement and/or other documentation in support of the amounts claimed) 49CFR24.401(e)
ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

LEGAL, CLOSING, AND
RELATED COSTS

$

_________

_________

TITLE SEARCH FEE

$

_________

_________

NOTARY FEE

$

_________

_________

RECORDING FEES

$

_________

_________

SURVEY COSTS

$

_________

_________

LENDER’S APPRAISAL FEE

$

_________

_________

LENDER’S APPLICATION FEE

$

_________

_________

CREDIT REPORT FEE

$

_________

_________

OWNER’S AND MORTGAGEE’S
EVIDENCE OF TITLE

$

_________

_________

ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

ESCROW FEE

$

__________

__________

TRANSFER TAXES

$

__________

__________

(that do not represent prepaid interest) $

__________

__________

CERTIFICATION FEE

$

__________

__________

HOME INSPECTION FEE

$

__________

__________

TERMITE INSPECTION FEE

$

__________

__________

COST OF POINTS
FOR MORTGAGE

$

__________

__________

OTHER (list) .......................

$

__________

__________

.............................................

$

__________

__________

.............................................

$

__________

__________

TOTAL ......

$

0.00
__________

0.00
__________

LOAN ORIGINATION
OR ASSUMPTION FEES

6. RENTAL ASSISTANCE PAYMENT PREVIOUSLY RECEIVED: (if any)

$ __________________

7. DOWNPAYMENT ADVANCED: (if any)

$ __________________

8.
SIGNATURE:

__________________________________________________

DATE: ______________

SIGNATURE:

_______________________________________

DATE: ______________

9. REMARKS:

DI-381 8

SECTION II – TO BE COMPLETED BY AGENCY
COMPUTATION OF AMOUNT OF DOWNPAYMENT

PRICE OF A COMPARABLE DWELLING:

$ _________________

$ _________________

TOTAL DOWNPAYMENT: (The lesser
of the difference between the
downpayment for comparable plus
incidental costs or the downpayment
actually paid plus incidental costs)

DOWNPAYMENT REQUIRED FOR
CONVENTIONAL MORTGAGE ON
COMPARABLE DWELLING:

$ ________________

PRICE PAID FOR REPLACEMENT
DWELLING:

$ _________________

RENTAL ASSISTANCE
PREVIOUSLY RECEIVED:

$ ________________

DOWNPAYMENT ACTUALLY PAID
ON REPLACEMENT DWELLING:

$ _________________

DOWNPAYMENT ADVANCED:
TOTAL AMOUNT DUE:

$ ________________
$ ________________

INCIDENTAL COSTS:

$ _________________

PAYMENT

RECOMMENDED:

AMOUNT

SIGNATURE

TITLE

DATE

_________________

_________________________________________

__________________

____________

APPROVED:

_________________

________________________________________

__________________

____________

FBMS INVOICE NO.:

_________________

DI-381 9