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Rigfrt d W ay /Lgerd Date Refawtion Reviewer Date <br /> ~ Oregon Department of Transportation REL~CATiON <br /> FIXED PAYMENT CLAtM <br /> Pay To: 1 ,Q ~ File No. <br /> Maiiitsg Address ~ ~ ~0 Name <br /> j ~ ~ Section <br /> highway <br /> ClaimahYs Name , ~ i ~ ~ j County <br /> C /v <br /> FAP No. <br /> I, L~i~,~,i N ~'0 , Proprietor of ~ ~ ~ A-~~:-t-~~ ~Vr`Q' ~ <br /> located at LI ~ J- ~ : ~ ~-i%'t ~ ~'it~~ ereby make a claim for a Fixed <br /> Payment in lieu of moving expenses as a displa ~ business, ? farm, ? non-profit organization <br /> (NPO). <br /> 1 understand that to be eligible for the fixed payment, 1 cannot be relocated without a substantial toss of <br /> not be a art of a commercial enterprise having <br /> t e eli ible I must p <br /> <br /> ~ further o b , <br /> i ti atrona e' and g . <br /> ex s g , <br /> ~ p r the same <br /> it b the State and which are uncle <br /> u ed <br /> ntities which are not bei acq y <br /> more than three other a n9 <br /> ownership and engaged in the same or similar business activities. <br /> I understand that the fixed payment is to be based on one-half the °annual net eamings° before Federal, <br /> State, and local income taxes during the two taxable years immediately preceding the tax year of <br /> displacement, not less than $1,000 nor more than $20,000. <br /> I understand that the amount of paymerrt I receive will be computed from the Oregon Income tax returns <br /> filed by myself (per ORS 281.070), copies of which are attached. ~ ~n~l USc.~j <br /> I understand that the fixed payment is in lieu of all other relocation benefits and that the premises must <br /> be vacated and left Gean and orderly. <br /> ~ ~.i2~ <br /> 1 certify that f am the proprietor and have operated the business, farm, or NPO for. ~ and <br /> that the statemerrts contained herein are true and correct to the best of my knowledge and belief. Based <br /> an th ve, claim a fixed payment of $ ~ /'~Ol <br /> / ~~S <br /> APPifcarn Date aPPlicarn Date <br /> The subject property was inspected on and found to be vacant, clean, and orderly. <br /> An inspection of the proprietor's Oregon Income Tax returns indicates that the proprietor should receive <br /> payment. I recommend that the proprietor be paid the sum of $ <br /> ;34-35G3 (11/001 <br /> <br />