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

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

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

Schedule C
Claim of Rental Replacement Housing Payments – Residential
(Under Sec. 204 (a), P.L.91-646, as amended)

Section 1 – To Be Completed By Claimant
1. NAME:

2. PROJECT/TRACT:

3. WHAT WAS THE MONTHLY RENTAL RATE OF THE

4. CHECK THE UTILITIES THAT WERE INCLUDED IN YOUR RENT:
❑ ELECTRIC

DWELLING YOU VACATED? $_________________

❑ 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

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

REPLACEMENT DWELLING? $__________________
8. REQUEST FOR
PAYMENT:

❑ GAS

❑ WATER

❑ OTHER

LUMP SUM

INSTALLMENT

FREQUENCY

❑

❑

_____________

AMOUNT OF
INSTALLMENT
$_____________

9.
SIGNATURE: ___________________________________________ SIGNATURE:
DATE: ___________________________________________

DATE:

___________________________________________
___________________________________________

Section 2 – 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)

$ ________________

PAYMENT

AMOUNT

NO ❑

SIGNATURE

TITLE

DATE

RECOMMENDED:

_________________

________________________________________

_________________

______________

APPROVED:

_________________

________________________________________

_________________

______________

FBMS INVOICE NO.:_________________
REMARKS:

DI-381 Schedule C - Page 1 of 1