DI-381 Claim for Relocation Payments - Residential - Schedule A

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Schedule A
Payment of Moving Costs – Residential
(Under Sec. 202, P.L.91-646, as amended)

Section 1 – To Be Completed By Claimant
1. NAME:
3. TYPE OF
PAYMENT
CLAIMED:

2. PROJECT/TRACT:
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/non-allowable)
FOR AGENCY USE ONLY

ITEM

AMOUNT CLAIMED

MOVING COSTS

$ _______________

$ ___________________________________

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 ❑

SUPPLEMENTARY ❑

FINAL ❑

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

STORAGE PERIOD: NUMBER OF MONTHS ______, ARE THE NUMBER OF MONTHS
STORAGE COSTS:

TOTAL COST INCURRED
$ ___________________

ACTUAL ❑

AMOUNT PREVIOUSLY RECEIVED
-

$ ____________________________

OR: ESTIMATED ❑

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: _________________________________________

SIGNATURE: __________________________________________

DATE: _______________________________________________

DATE: ________________________________________________

DI-381 Schedule A - Page 1 of 2

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Section 2 – 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.
2. Packing and unpacking, crating and uncrating of personal property.
3. Disconnecting, dismantling, removing, reassembling, and reinstalling
relocated household appliances, and other personal property.
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.

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.
8. 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.
10. Other moving-related expenses that are not listed as ineligible under
Non-allowable Moving Expenses, as the Agency determines to be
reasonable and necessary.

NON-ALLOWABLE 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 Schedule A - Page 2 of 2