Form HUD-40054 Residential Claim for Moving and Related Expenses

Residential Claim for Moving
and Related Expenses
(49 CFR 24.301 and 24.302)
See back of page for Public Reporting Burden and
Privacy Act Statements before completing this form
For Agency Name of Agency
Use Only

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

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

Project Name or Number

Case Number

Instructions: This claim form is for the use of families and individuals applying for payment of residential moving and related expenses under the Uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (URA). You may be eligible to apply for either (1) a fixed payment (see 24.302), or (2) payment for actual reasonable moving
costs and related expenses (see 24.301), or (3) in some cases, a payment based on a combination of moving options (contact Agency). All claims for actual expenses must
be supported by receipts or other acceptable evidence. The Agency will explain the differences between the types of moving options 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 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 that 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)).
1. Your Name(s) (You are the Claimant(s)) and Present Mailing Address
1a. Telephone Number(s)

2. Have All Members of the Household Moved to the Same Dwelling?
Yes
No
(If “No,” list the names of all members and the addresses to which they moved in the Remarks Section.)
Number of Rooms
Dwelling
Address (include Apartment No.)
of Furniture? *

Date
Occupied

Date
Vacated

3. Unit That You
Moved From
* Excluding bathrooms,

4. Unit That You
Moved To
5. Is This a Final Claim?

hallways and closets.

Yes

No

6. 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.) Your signature on this claim form constitutes certification. See 49 CFR 24.208(g) & (h) for hardship exceptions.
Please address only the category (Individual or family) that describes your occupancy status. For item (2), please fill in the correct number of persons.
RESIDENTIAL HOUSEHOLDS
(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.

7. Computation of Payment (See 49 CFR 24.301 and 24.302)
Instructions: You may be eligible to apply for either (1) a fixed payment (see 24.302), or (2) payment for actual and reasonable moving costs and related expenses
(see 24.301), or (3) in some cases, a payment based on a combination of moving options (see 24.301(b)). The computation table in this section provides you with
the ability to compute your payment based on one or a combination of moving options depending on your eligibility and your needs and desires.
A fixed payment is used to compute a payment based on the numbers of rooms of furniture within the displacement dwelling. The Residential Fixed Moving Cost Schedule
available at www.hud.gov/relocation, will provide the payment amount for the state in which the displacement occurred. (Note: for persons occupying a dormitory style
room or where the move is performed by the Agency at no cost to the displaced person, the payment amount is limited to the amount specified for such moves on the
Fixed Moving Cost Schedule.) If you choose to claim a fixed payment, fill in the applicable schedule amount in column 7c Line (3). In some cases, persons who plans
to claim only a fixed payment may also be eligible for additional moving options to move personal property located outside the dwelling and not considered in the Fixed
Moving Cost Schedule (jungle gym, hot tub, etc.) or for personal property requiring specialized moving assistance within the dwelling (piano, pool table, medical equipment,
etc.). In these situations you may also be eligible for a payment based on actual costs for a commerical move and/or self move for these items. Contact the Agency
for further assistance. If the Agency determines you are eligible for other moving options in addition to the fixed payment, fill in all applicable claim information requested
for the type(s) of moving option specified in the table.
7a. Commercial Move
(Actual Costs)
(Based on lower of 2 bids)
Claimant

Agency Use

7b. Self Move
(Actual Costs)
(Not to exceed cost of
commerical move)
Claimant
Agency Use

7c. Self Move
(Fixed Schedule)
(See 49 CFR 24.302)
Claimant

Agency Use

(1) Moving Cost Expenses (49 CFR 24.301(g)(1-7); see page 2)
(Do not include storage costs listed separately below). [For
Mobile Home Owner Occupants also include 24.301(g)(8-10),
if applicable.]
(2) Storage Cost (Requires prior agency approval) (Not to
exceed 12 months)
(3) Fixed Moving Cost Schedule Amount (Based on number of
rooms of furniture in Item 3). For amount see Moving Cost
Schedule available at www.hud.gov/relocation.
(4) Other (Explain in Remarks Section)
(5) Total Amount of Claim.
(6) Amount Previously Received, if any.
(7) Amount Requested (Subtract line (6) from line (5)
(8) Total Amount Requested - Combination Moves Only
(add applicable columns 7(a)(7), 7(b)(7) and 7(c)(7))
Previous versions obsolete.

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form HUD-40054 (4/2005)

8. Certification By Claimant(s): I certify that this claim and supporting information are true and complete and that I have not been paid
for these expenses by any other source. I ask that the amount on line (7) of Item 7 or line (8) of Item 7 for combination moves be
me
the contractor(s) (as specified in the Remarks Section).
paid to
Signature(s) of Claimant(s) & 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 the Agency
Payment Action
Amount of Payment
9. Recommended

$

10. Approved

$

Signature

Name (Type or Print)

Date (mm/dd/yyyy)

Remarks (Attach additional sheets, if necessary)

Additional sheets attached?

Yes

No

Eligible Actual Residential Moving Expenses (49 CFR 24.301(g)(1-10)
(1) Transportation of the displaced person and personal property. Transportation costs for a distance beyond 50 miles are not eligible, unless the
Agency determines that relocation beyond 50 miles is justified.
Packing, crating, unpacking, and uncrating of the personal property.
Disconnecting, dismantling, removing, reassembling, and reinstalling relocated household appliances and other personal property. 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.
(4) Storage of the personal property for a period not to exceed l2 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.
(7) Other moving-related expenses that are not listed as ineligible under § 24.301(h), as the Agency determines to be reasonable and necessary.
(8) 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.
(9) The reasonable cost of repairs and/or modifications so that a mobile home can be moved and/or made decent, safe, and sanitary.
(10) 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 the Agency determines that payment of the fee is necessary to effect relocation.
(2)
(3)

Public reporting burden for this collection of information is estimated to average 30 minutes 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 payment for 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 information is needed to determine whether you are eligible to receive a payment for moving and related
expenses. You are not required by law to furnish this information, but if you do not provide it, you may not receive any payment for these expenses or it
may take longer to pay you. 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 versions obsolete.

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form HUD-40054 (4/2005)