Form DI-382 Claim for Relocation Payments - Nonresidential

Claim for Relocation Payments - Residential, DI-381; Claim for Relocation Payments - Nonresidential, DI-382

DI-382_Fillable_5-13-2015

Claim for Relocation Payments - Nonresidential

OMB: 1084-0010

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DEPARTMENT OF THE INTERIOR

OMB CONTROL NO.

CLAIM FOR RELOCATION PAYMENTS – NONRESIDENTIAL

1084-0010

(Public Law 91-646, as amended)

Expires

PROJECT/TRACT:

AGENCY:

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, storage, actual direct loss of property, search, and reestablishment expenses
or a payment in lieu of these expenses (42 USC 4622). 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 the 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 forms.
2. NAME/TITLE:
(person filing claim for claimant)

1. NAME:
(claimant)

MAILING ADDRESS:

MAILING ADDRESS:
TAX ID NO. OR SOCIAL SECURITY NO.:
TELEPHONE NUMBER: (

)

TELEPHONE NUMBER: (

3. TYPE OF CONCERN:	 BUSINESS ❑

FARM OPERATION ❑

4. TYPE OF OWNERSHIP: SOLE PROPRIETORSHIP ❑

)

NONPROFIT ORGANIZATION ❑

CORPORATION ❑

PARTNERSHIP ❑

NONPROFIT ORGANIZATION ❑

Please address only the category that describes your citizenship status.  For item (2), please fill in the correct number of partners.
(49CFR24.208(a)) Your signature on this claim form constitutes certification.
(1)	 Sole Proprietorship – I certify that I am (check one)  ___ a citizen or national of the United States; ___ an alien lawfully present in the
United States.
(2)	 Partnership – I certify that there are ____ partners in the partnership and that ____ are citizens or nationals of the United States and
____ are aliens lawfully present in the United States.
(3)	 Corporation – I certify that (Name of Corporation) __________________________ is established pursuant to State law and is authorized to
conduct business in the United States.
5. DATES YOU OCCUPIED THE PROPERTY: FROM  __________  TO __________
6. DID CONCERN DISCONTINUE OPERATION?  __________
7. DOES CONCERN PLAN TO REESTABLISH?  __________
8. DATE YOU OCCUPIED THE REPLACEMENT:  __________
9. ADDRESS OF REPLACEMENT:

10. TYPE OF CLAIM:
11. TYPE OF PAYMENT:

INITIAL ❑
ACTUAL ❑

SUPPLEMENTARY ❑ 	 FINAL ❑
FIXED PAYMENT (complete item 13 on reverse) ❑

12. CLAIM:
MOVING AND STORAGE EXPENSES (Attach completed schedule A)	

AMOUNT

FOR AGENCY USE ONLY

$

$

ACTUAL DIRECT LOSSES OF PROPERTY (Attach completed schedule B) 	 $

$

REASONABLE SEARCH EXPENSES (Attach completed schedule C)

$	

$

REESTABLISHMENT EXPENSES (Attach completed schedule D)

$	

$

FIXED PAYMENT

$	

$	
DI-382 1
(04/15)

13. FIXED PAYMENT IN LIEU OF ACTUAL EXPENSES:
FOR BUSINESS OR FARM OPERATION

FOR NONPROFIT ORGANIZATION

What	were	the	annual	net	earnings,	including	compensation	to	owner,	the		 	
owner’s	spouse	and	dependents,	before	Federal,	State,	and	local	income		 	
taxes	for	the	two	taxable	years	immediately	prior	to	the	taxable	year	of		 	
displacement.		(Proof	of	net	earnings	shall	be	furnished	through	income	tax		
returns,	certified	financial	statements	or	other	evidence.)
TAX	YEAR:		______	
NET EARNINGS:
$	____________		

TAX	YEAR:		______

	

PERIOD:	____________	 				PERIOD:	____________

AVERAGE
AMOUNT

NET EARNINGS:
$	____________		

What	were	the	annual	gross	revenues,	less	administrative	expenses	for	the	two		
12-month	periods	prior	to	acquisition?		(Certified	financial	statements	or	financial		
documents	must	be	provided	for	any	payment	in	excess	of	$1000.)

AMOUNT

AVERAGE
AMOUNT

AMOUNT

$	____________								$	____________										$	__________

$	__________

Name(s)	used	on	income	tax	return(s)	or	other	acceptable	proof	of
income:

Is	organization	incorporated	under	applicable	laws	of	a

Employer	identification	number(s)	shown	on	tax	return(s)	
(if	tax	returns	used	as	proof	of	income):

Is	organization	exempt	from	paying	Federal	income
taxes	under	section	501	of	the	Internal	 	
Revenue	Code	(26	U.S.C.	501)?
YES ❑

State	as	a	nonprofit	organization?			

	

YES ❑

NO ❑

NO ❑

14. NAME AND ADDRESS OF PERSON(S)
TO WHOM PAYMENTS ARE TO BE MADE:

15. 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:	___________________________________________________
(claimant	or	agent)

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	both.

SECTION II – TO BE COMPLETED BY AGENCY
AMOUNT	PREVIOUSLY	PAID			(if	any).....		$ __________________
PAYMENT
RECOMMENDED:
APPROVED:
FBMS INVOICE NO.:

SIGNATURE

TITLE

DATE

___________________

_____________________________________________

___________________

___________________

___________________

_____________________________________________

___________________

___________________

AMOUNT

___________________
DI-382	2

SCHEDULE A
MOVING AND RELATED COSTS – NONRESIDENTIAL
(Under Sec. 202, P.L. 91-646, as amended)

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

3. TYPE OF MOVE:

2. PROJECT/TRACT:

SELF ❑

COMMERCIAL ❑

SELF AND COMMERCIAL ❑

4. MOVING COSTS: (See reverse for allowable/nonallowable expenses)
ITEM

CONTRACTOR/ADDRESS/PHONE NUMBER

AMOUNT CLAIMED

FOR AGENCY USE ONLY

MOVING: .....................................................................................................................

$

$

ELECTRICAL: ............................................................................................................

$

$

MECHANICAL: ...........................................................................................................

$

$

PLUMBING: ................................................................................................................

$

$

CARPENTRY: .............................................................................................................

$

$

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

$

$

__________ ...............................................................................................................

$

$

__________ ...............................................................................................................

$

$

__________ ...............................................................................................................

$

$

TOTAL ...........................................................

$

0.00

$

0.00

5. STORAGE COSTS:
TYPE OF CLAIM:

INITIAL ❑

SUPPLEMENTARY ❑

FINAL ❑

NAME AND ADDRESS OF STORAGE COMPANY:

STORAGE PERIOD: NUMBER OF MONTHS ______, ARE THE NUMBER OF MONTHS
DATE PROPERTY WAS MOVED: TO STORAGE ___________________________;

ACTUAL ❑

OR ESTIMATED ❑

FROM STORAGE ______________________________

STORAGE COSTS: $ _____________
DESCRIPTION OF PROPERTY STORED: (List each major item separately or attach a Bill of Lading from the moving company showing the
items stored.)

DI-382 3

6. REMARKS:

7. SIGNATURE:

SIGNATURE:
___________________________________________	

DATE:	 ___________________________________________

___________________________________________
DATE:	

___________________________________________

SECTION II – TO BE COMPLETED BY AGENCY
MOVING ESTIMATE OBTAINED BY THE AGENCY: 	

$   ____________________	

MOVING COSTS:	

$	 ____________________	

STORAGE COSTS:	

$	 ____________________	

ADVANCE RECEIVED (if any):	

$	 ____________________

PAYMENT

SIGNATURE

AMOUNT

TITLE

DATE

RECOMMENDED:

___________________

_____________________________________________

___________________

________________

APPROVED:

___________________

_____________________________________________

___________________

________________

FBMS INVOICE NO.: ___________________
ALLOWABLE MOVING EXPENSES
1. Transportation of personal property not to exceed 50 miles except
where the Agency determines that relocation beyond the 50-mile	
Area is justified.
2. Packing, crating, unpacking and uncrating personal property.
3. Disconnecting, dismantling, removing, reassembling and
reinstalling relocated machinery, equipment and other personal
property, including substitute personal property.
4. Storage of the 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 personal property in
connection with the move and necessary storage.
6. Any license, permit, or certification required of the displaced person
at the replacement location. However, the payment may be based
on the remaining useful life of the existing license, permit, fees or
certification.
7. 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.
8. Professional	services	determined to be actual, reasonable and
necessary	for	planning,	moving	and	installing relocated	personal
property	at	the	replacement	location.

9. Relettering signs and replacing stationery on hand at the time of
displacement and making updates to other media	that	are	made	
obsolete as a result of the move.
	10. Purchase of substitute personal property.
1	1.	Payment for low value/high bulk personal property.
	12. Connection to available nearby utilities from the right-of-way to
improvements at the replacement site.  
13. Professional services performed prior to the purchase or lease of a
replacement site to determine its suitability for the displaced person’s
business operation including but not limited to, soil testing, feasibility
and marketing studies (excluding any fees or commissions directly
related to the purchase or lease of such site). At the discretion of the
Agency a reasonable pre-approved hourly rate may be established.
(See appendix A, § 24.303(b).)
14. Impact fees or one time assessments for anticipated heavy utility
usage, as determined necessary by the Agency.
15. 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 any structures of other real property improvement in
which the displaced person reserved ownership.
2. Interest on loan to cover moving expenses.
3. Loss of goodwill.
4. Loss of profits.
5. Loss of trained employees.
6. Additional operating expenses incurred because of operating in a
new location except as specifically provided for.

7. Personal injury.
8. Any legal fee or other cost for preparing a claim for a relocation
payment or for representing the claimant before the Agency.
9. Physical changes to the real property at the replacement location
except as specifically provided for.
	10. Costs for storage of personal property on real property already owned
or leased by the displaced person.
11. Refundable security and utility deposits.

DI-382 4

SCHEDULE B
DIRECT LOSS OF PERSONAL PROPERTY – NONRESIDENTIAL
(Under Sec. 202, P.L. 91-646, as amended)

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

2. PROJECT/TRACT:

3. TANGIBLE PERSONAL PROPERTY:
ITEM
(list)

FAIR MARKET VALUE
FOR CONTINUED USE
AT PRESENT LOCATION

-

NET PROCEEDS
FROM SALE

=

VALUE NOT
RECOVERED
BY SALE

FOR AGENCY
USE ONLY

1.

$

$

$

0.00

$

2.

$

$

$

0.00

$

3.

$

$

$

0.00

$

4.

$

$

$

0.00

$

5.

$

$

$

0.00

$

6.

$

$

$

0.00

$

7.

$

$

$

0.00

$

8.

$

$

$

0.00

$

COST OF SALE: ...............................................................................................................

$

TOTAL: ................................................................................................................................

$

$

0.00

$

0.00

Actual direct loss of tangible personal property incurred as a result of moving or discontinuing the business or farm operation. The payment shall consist
of the lesser of: (i)The fair market value in place of the item, as is for continued use, less the proceeds from its sale. (To be eligible for payment, the
claimant must make a good faith effort to sell the personal property, unless the Agency determines that such effort is not necessary. When payment
for property loss is claimed for goods held for sale, the market value shall be based on the cost of the goods to the business, not the potential selling
prices.); or (ii) The estimated cost of moving the item as is, but not including any allowance for storage; or for reconnecting a piece of equipment if the
equipment is in storage or not being used at the acquired site. If the business or farm operation is discontinued, the estimated cost of moving the item
shall be based on a moving distance of 50 miles. The reasonable cost incurred in attempting to sell an item that is not to be relocated.
4. REMARKS: (Use other side if necessary)

5. RELEASE: I (We) hereby release to the displacing agency ownership and title to all personal property remaining on the acquired site, for which
the claimant has received or will receive a payment for direct loss of property.
SIGNATURE:

SIGNATURE:

DATE:

DATE:

SECTION II – TO BE COMPLETED BY AGENCY
TOTAL COSTS ...............................................................................................................................

$ _____________________

ESTIMATED COSTS OF MOVING PROPERTY............................................................................

$ _____________________

AMOUNT

SIGNATURE

RECOMMENDED:

________________

______________________________________

____________________

_____________

APPROVED:

________________

______________________________________

____________________

_____________

PAYMENT

TITLE

DATE

FBMS INVOICE NO.: ________________
DI-382 5

SCHEDULE C
SEARCH EXPENSES – NONRESIDENTIAL
(Under Sec. 202, P.L. 91-646, as amended)

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

2. PROJECT/TRACT:

3. ACTUAL EXPENSES:

AMOUNT CLAIMED

FOR AGENCY USE ONLY

SEARCHING TIME ........ ______ (hours) at ______ (rate) ................................... $

0.00

$

TRANSPORTATION ....... ______ (miles) at ______ (rate) ................................... $

0.00

$

LODGING ...................... ______ (nights) at ______ (rate) ................................... $

0.00

$

COST OF MEALS ....................................................................................................... $

$

TIME SPENT IN OBTAINING PERMITS
AND ATTENDING ZONING HEARINGS. ....... ______ (hours) at ______ (rate) ...... $

0.00

$

TIME SPENT NEGOTIATING THE
PURCHASE OF A REPLACEMENT SITE ..... ______ (hours) at ______ (rate) ...... $

0.00

$

FEES PAID TO REAL ESTATE AGENTS OR BROKERS (excluding commissions) . $

$

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

$

.................................................................................................................................... $

$

TOTAL ......................................................................................................................... $

$

0.00

0.00

4. REMARKS:

5. SIGNATURE:

SIGNATURE:
___________________________________________

DATE: ___________________________________________

___________________________________________
DATE:

___________________________________________

SECTION II – TO BE COMPLETED BY AGENCY

PAYMENT

AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

___________________

_____________________________________________

___________________

________________

APPROVED:

___________________

_____________________________________________

___________________

________________

FBMS INVOICE NO.: ___________________
DI-382 6

SCHEDULE D
REESTABLISHMENT EXPENSES – NONRESIDENTIAL
(Under Sec. 202. P.L. 91-646, as amended)

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

2. PROJECT/TRACT:

3. REESTABLISHMENT EXPENSES: (See reverse for allowable/nonallowable expenses)
ITEM (list)

AMOUNT CLAIMED

FOR AGENCY USE ONLY

1. ......................................................................................

$

$

2. ......................................................................................

$

$

3. ......................................................................................

$

$

4. ......................................................................................

$

$

5. ......................................................................................

$

$

6. ......................................................................................

$

$

7. ......................................................................................

$

$

8. ......................................................................................

$

$

9. ......................................................................................

$

$

10. ......................................................................................

$

$

11. ......................................................................................

$

$

12. ......................................................................................

$

$

13. ......................................................................................

$

$

14. ......................................................................................

$

$

TOTAL ..................................................................................

$

0.00

$

0.00

4. REMARKS:

5. SIGNATURE:

SIGNATURE:
___________________________________________

DATE: ___________________________________________

___________________________________________
DATE:

___________________________________________

DI-382 7

SECTION II – TO BE COMPLETED BY AGENCY
REESTABLISHMENT EXPENSES ........................

$ ________________

ADVANCE RECEIVED (if any) ..............................

$ ________________

PAYMENT

AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

___________________

_____________________________________________

___________________

________________

APPROVED:

___________________

_____________________________________________

___________________

________________

FBMS INVOICE NO.: ___________________
REMARKS:

REESTABLISHMENT EXPENSES CAN ONLY BE PAID TO A BUSINESS HAVING NOT MORE THAN 500 EMPLOYEES WORKING AT THE
SITE ACQUIRED OR DISPLACED BY A PROGRAM OR PROJECT, WHICH SITE IS THE LOCATION OF ECONOMIC ACTIVITY OR A FARM OR
NONPROFIT ORGANIZATION. 49CFR24.2(a)(24)
ELIGIBLE EXPENSES

INELIGIBLE EXPENSES

1. Repairs or Improvements to the replacement property as required
by Federal, State, or local law, code or ordinance.

1. Purchase capital assets, such as office furniture, filing cabinets,
machinery, or trade fixtures.

2. Modifications to the replacement property to accommodate the
business operation or make replacement structures suitable for
conducting the business.

2. Purchase of manufacturing materials, production supplies,
product inventory, or other items used in the normal course of the
business operation.

3. Construction and installation costs for exterior signing to
advertise the business.

3. Interest on money borrowed to make the move or purchase the
replacement property.

4. Redecoration or replacement of soiled or worn surfaces, such as
paint, paneling, or carpeting.

4. Payment to a part time business in the home which does not
contribute materially to the household income.

5. Licenses, fees and permits when not paid as part of moving
expenses.
6. Advertisement of replacement location.
7. Estimated increased costs of operation during the first two years
at the replacement site for such items as lease or rental charges,
personal or real property taxes, insurance premiums and utility
charges (excluding impact fees).
8. For businesses, farms or nonprofit organizations this includes
machinery, equipment, substitute personal property, and
connections to utilities available within the building; it also
includes modifications to the personal property, including those
mandated by Federal, State or local law, code or ordinance,
necessary to adapt it to the replacement structure, the
replacement site, or the utilities at the replacement site, and
modifications necessary to adapt the utilities at the replacement
site to the personal property.
9. Other items that the Agency considers essential to the
reestablishment of the business.

DI-382 8


File Typeapplication/pdf
File TitleClaim for Relocation Payments – Nonresidential (DI-382)
AuthorMark Hall - DOI/NBC Creative Communication Services GRAPHICS
File Modified2015-07-02
File Created1999-09-20

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