HUD-40055 Claim for Actual Reasonable Moving and Related Expenses-

U.S. Department of Housing
and Urban Development

Claim for Actual
Reasonable
Moving and Related
Expenses Nonresidential
(49 CFR 24 Subpart D)
For Agency Name of Agency
Use Only

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

Project Name or Number

Case Number

Instructions: This claim form is for the use of displaced businesses, nonprofit organizations, and farms that wish to claim a payment for
Actual Reasonable Moving and Related Expenses, including Reestablishment Expenses, rather than claim a Fixed Payment, under
the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (URA). 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)).
Attach supplemental pages as necessary. All expenses must be thoroughly identified and be accompanied by receipts or other
appropriate documentation to be eligible for payment. Professional services and other claims for time expended based on salaries,
earnings or fees related to 49 CFR 24.301(g)(12), 24.301(g)(17)(iii)-(vi), and 24.303(b), must be actual, reasonable, necessary, and should
be preapproved by the Agency.
(Eligible Moving Expenses: See 24.301(g)(1)-(7); 24.301(g)(11)-(18) & 24.303; Ineligible Moving Expenses: See 24.301(h))
(Eligible Reestablishment Expenses: See 24.304(a); Ineligible Reestablishment Expenses: See 24.304(b))

Section A. General
1. Name of Business, Farm or Nonprofit Organization

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

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

4a. Address to which Business, Farm or Nonprofit Organization moved

5. Type of Operation (Check One)
Business

Farm Operation

Nonprofit Organization

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

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

6. Type of Ownership (Check One)

7. Is this a Final Claim?

Sole Proprietorship

Corporation

Yes

Partnership

Nonprofit Organization

No (If “No," attach an explanation)

8. 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.
I certify that I am: (check one)
_____ a citizen or national of the United States
_____ an alien lawfully present in the United States.

Previous editions are obsolete

(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.

Page 1 of 4

(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-40055
(04/2005)

Section B. Supporting Data for Moving Expenses (Not identified in Sections C, D, E, F or G) (49 CFR 24.301(d) & 24.301(e)) (Attach supplemental page
if additional space is needed and attached receipts for costs incurred.) (Identify if move is commerical move
, self move
, or combination move
;
if combination move, identify each expense as commerical or self move.)
Expense Identification
Amount Claimed
For Agency Use Only
(1)

$

$

$

$

(2)
(3)
(4)
(5) Total Costs (Include this amount in line (1) of Item 9, Total)
Section C. Supporting Data for Storage Costs (49 CFR 24. 301(g)(4))
Is This a Final Claim for Storage?
Yes
No
Date Moved to Storage
(mm/dd/yyyy)

Name and Address of Storage Company

Date Moved From Storage
(mm/dd/yyyy)
Computation of Storage Costs

Item

Amount

Monthly Rate for Storage

For Agency Use Only

$

$

$

$

Number of Months in Storage
Total Storage Costs (Include this amount in line (1) of Item 9, Total)
Description of Property Stored (List may be attached)
Section D. Supporting Data for Searching Expenses (49 CFR 24.301(g)(17))

Amount Claimed

(1) Searching Time
Number of Hours (
) x Hourly Rate of Earnings (
) =
(2) Time Spent Obtaining Permits, Attending Zoning Hearings
Number of Hours (
) x Hourly Rate of Earnings (
) =
(3) Time Spent Negotiating Purchase/Lease of Replacement Site
Number of Hours (
) x Hourly Rate of Earnings (
) =
(4) Transportation (Consult with Agency on allowable rate per mile of personal vehicle)
(5) Lodging (Dates:
Attach receipts)
(6) Fees Paid to Real Estate Broker or Agent, (Excluding fees or commissions related to site purchase)
(Attach contract or other evidence)
(7) Cost of Meals
(8) Other Expenses (Specify and attach receipts)
(9) Total Searching Expenses
(Add lines (1) thru (9). Include this amount, or $2,500, whichever is less, in line (1) of Item 9 Total.)

For Agency Use Only

$

$

$

$

$
$
$

$
$
$

$
$
$

$
$
$

$

$

Section E. Supporting Data for Payment for Actual Direct Loss of Personal Property (List separately each item for which amount claimed in Column
(f) is more than $500. Other Items may be grouped together. The Agency will advise on acceptable method for listing items. Attach additional
sheets, as needed.) (49 CFR 24.301(g)(14))
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Identify Personal Property
Fair Market Value As Is Proceeds From Value Not Recovered Estimated Cost of
Amount Claimed For Agency
for Which Payment for
For Continued Use At
Sale
By Sale
Moving Old Property
(Lesser of
Use Only
Actual Direct Loss is
Present Location
(Column (b) minus
As Is (To be entered Column (d) or
Requested
(Attach appraisals
Column (c))
by Agency)
(e))
or other evidence)
(see 24.301(g)(14)(ii))
$

$

$

$

Claimant's Release of Personal Property
(1) Total (Add all entries in column (f) above)
I/We release to the Agency ownership of all personal property
(2) Cost of Effort to Sell Property (e.g., advertising)
remaining on the real property.
(49 CFR 24.301(g)(15))
Signature(s) of Claimant(s) or Agent
Date (mm/dd/yyyy)
(3) Total Amount Claimed (Add lines (1) and (2).
Include this amount in line (1) of Item 9 Total)
Previous editions are obsolete

Page 2 of 4

$

$

$
$

$
$

$

$

form HUD-40055
(04/2005)

Section F. Supporting Data for Substitute Personal Property. List separately each item for which amount claimed in column (f) is more than $500.
Other items may be grouped together. The agency will advise on acceptable method of listing items. Attach additional sheets, as needed.)
(49 CFR 24.301(g)(16))
(a)
Identify Substitute
Personal Property
for which Payment
is Requested

(b)
Actual Cost of
Substitute Property
Delivered and Installed
at New Location
(Attach documentation)

(c)
(d)
(e)
(f)
(g)
Proceeds From
Net Cost of
Estimated Cost of
Amount Claimed For Agency
Sale orTrade-in of
Substitute
Moving and Reinstalling
(Lesser of
Use Only
Property That Was Personal Property Replaced Item (To be
column (d)
Replaced
(Column (b) minus entered by agency)
or (e))
Column (c))
(see 24.301(g)(16)(ii))

$

$

$

$

Claimant's Release Of Personal Property
(1) Total (Add all entries in column (f) above)
I/We release to the Agency ownership of all personal
(2) Cost of Effort to Sell Property (e.g., advertising)
property remaining on the real property.
(49 CFR 24.301(g)(15))
Signature(s) of Claimant(s) or Agent
Date (mm/dd/yyyy)
(3) Total Amount Claimed (Add lines (1) and (2).
Include this amount in line (1) of Item 9 Total)
Section G. Supporting Data for Related Nonresidential Expenses (49 CFR 24.303)
Only if applicable and Determined Actual, Reasonable and Necessary. (Attach supplemental page, if needed)

$

$

$

$

$
$

$
$

Amount
Claimed

Expense Identification
(1) Utility Connections from Right-of-Way to Improvements at Replacement Site.
(2) Professional Services for Site Suitability Determination
(Based on Agency pre-approved reasonable hourly rates) Number of Hours (
) X Hourly Rate of Earnings ($

For Agency
Use Only

) =

(3) Impact Fees or One Time Assessments for Utility Usage.
Total Related Nonresidential Expenses: (Add lines (1) through (3))
(Include this amount in line (1) of Item 9 Total)
Section H. Supporting Data for Reestablishment Expenses. (49 CFR 24.304) (Attach supplemental page if additional
space is needed.)
Amount
Claimed

Expense Identification

For Agency
Use Only

(1)
$

$

$

$

(2)

(3)

(4)

(5) Total Costs (Enter this amount, or $10,000, whichever is less, on line (2) of Item 9)
Previous editions are obsolete

Page 3 of 4

form HUD-40055
(04/2005)

Section I. 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)
9. Computation of Payment
Item

Amount

For Agency Use OnlyTher

(1) Moving Expenses (From Section B, C, D, E, F, G)

$

$

(2) Reestablishment Expenses (From Section H)

$

$

(3) Other (Attach explanation)

$

$

(4) Total Amount Claimed (Add lines (1) thru (3))

$

$

(5) Amount Previously Received, if any

$

$

(6) Amount Requested (Subtract line (5) from line (4))

$

$

To Be Completed by Agency
Payment Action

Amount of Payment

10. Recommended

$

11. Approved

$

Signature

Name (Type or Print)

Date (mm/dd/yyyy)

Remarks:

Public reporting burden for this collection of information is estimated to average 1.5 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 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 form is for the use of displaced businesses, nonprofit organizations, and farm operators that wish to apply
for a Payment for Actual Reasonable Moving and Related Expenses, including Reestablishment Expenses, rather than apply for a Fixed Payment.
(The maximum 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 Agenecy 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 explanationion of the reason. If you are not satisfied with the Agency’s determination, you may appeal the determination. The Agency will explain
how to amke an appeal. This information is being collected under the authority of the Uniform Relocation Assistance and Real Property Acquisition Act of
1970. The information may be made available to a Federal Agency for review.
Previous editions are obsolete
form HUD-40055
Page 4 of 4
(04/2005)