Relocation Assistance Claim

RELOCATION ASSISTANCE CLAIM

TABLE OF CONTENTS

1. Claimant Information
2. Displacing Agency Information
3. Eligibility Determination
4. Type of Displacement
5. Moving Expense Claim
6. Replacement Housing Payment Claim
7. Advisory Services Certification
8. Supporting Documentation
9. Certification and Signature
10. Appeal Rights

I. CLAIMANT INFORMATION

Full Name: [________________________________]

Current Address: [________________________________]

City/State/ZIP: [________________________________]

Phone: [________________________________]

Email: [________________________________]

Displaced Property Address: [________________________________]

Project Name/Number: [________________________________]

Parcel/Case No.: [________________________________]

Date of Displacement Notice: [__/__/____]

Date Vacated/Will Vacate: [__/__/____]

II. DISPLACING AGENCY INFORMATION

Agency Name: [________________________________]

Contact Person: [________________________________]

Address: [________________________________]

Phone: [________________________________]

Federal Funding Source (if known): ☐ FHWA ☐ HUD ☐ DOT ☐ Other: [________________________________]

III. ELIGIBILITY DETERMINATION

Type of Claimant:

☐ Residential Owner-Occupant (occupied for at least 90 days — 42 U.S.C. § 4623)
☐ Residential Tenant (occupied for at least 90 days — 42 U.S.C. § 4624)
☐ Business Owner/Operator (49 C.F.R. § 24.304)
☐ Farm Operation (49 C.F.R. § 24.304)
☐ Nonprofit Organization (49 C.F.R. § 24.304)

Length of Occupancy at Displaced Property:

☐ Less than 90 days ☐ 90 days to 1 year ☐ 1–3 years ☐ Over 3 years

IV. TYPE OF DISPLACEMENT

☐ Total acquisition of property
☐ Partial acquisition rendering property uninhabitable/unusable
☐ Rehabilitation project requiring temporary relocation
☐ Demolition project
☐ Code enforcement or other government action
☐ Other: [________________________________]

V. MOVING EXPENSE CLAIM

A. Residential Moving Expenses (42 U.S.C. § 4622)

Method of Claim:

☐ Actual Reasonable Moving Expenses (with documentation)

☐ Fixed Moving Expense Schedule (per FHWA/agency schedule)

Rooms of furniture: [____]
Fixed payment amount: $[________________________________]

B. Business/Farm/Nonprofit Moving Expenses (49 C.F.R. § 24.303-304)

☐ In Lieu of Moving Expenses — Fixed Payment (business/farm only, per 42 U.S.C. § 4622(c))

Average annual net earnings: $[________________________________]
Fixed payment claimed (min. $1,000 / max. $53,200 under current 49 C.F.R. § 24.305): $[________________________________]

VI. REPLACEMENT HOUSING PAYMENT CLAIM

A. Homeowner — 90-Day Occupant (42 U.S.C. § 4623)

Maximum statutory cap: $[________________________________]

B. Tenant — 90-Day Occupant (42 U.S.C. § 4624)

Maximum statutory cap: $[________________________________]

VII. ADVISORY SERVICES CERTIFICATION

Under 42 U.S.C. § 4625, the displacing agency is required to provide relocation advisory services. Please confirm:

☐ I was offered advisory assistance regarding available housing/business locations.
☐ I was provided comparable replacement dwelling/site referrals.
☐ I was informed of my relocation rights and benefits.
☐ I was NOT provided required advisory services (explain): [________________________________]

VIII. SUPPORTING DOCUMENTATION

Attach the following (check all included):

☐ Copy of displacement/acquisition notice
☐ Moving company estimates or invoices (minimum 2 estimates recommended)
☐ Receipts for all claimed moving expenses
☐ Proof of occupancy (lease, utility bills, tax records)
☐ Settlement statement for replacement dwelling
☐ Mortgage documents for replacement dwelling
☐ Business financial records (tax returns, P&L statements) if applicable
☐ Photographs of personal property moved
☐ Other: [________________________________]

IX. CERTIFICATION AND SIGNATURE

I, the undersigned, certify under penalty of perjury that the information contained in this claim is true and correct to the best of my knowledge, and that the expenses claimed were actually incurred or will be incurred in connection with my displacement from the identified property.

Claimant Signature: [________________________________]

Printed Name: [________________________________]

Date: [__/__/____]

Prepared by (if representative):

[________________________________]
[________________________________]
Telephone: [________________________________]
Email: [________________________________]

X. APPEAL RIGHTS

If this claim is denied in whole or in part, the claimant has the right to:

1. Request a written explanation of the denial from the displacing agency.
2. File a written appeal with the agency within [____] days of the denial.
3. Receive a prompt, fair review by a person not involved in the original decision (49 C.F.R. § 24.10).
4. Seek judicial review in a court of competent jurisdiction if the administrative appeal is denied.

STATE-SPECIFIC CONSIDERATIONS

California: Cal. Gov. Code § 7260 et seq. provides relocation benefits that may exceed federal minimums. Cal. Code Regs. tit. 25, § 6000 et seq. sets detailed claim procedures.

Texas: Tex. Prop. Code § 21.046 requires relocation advisory assistance. TxDOT follows 49 C.F.R. Part 24 for federally funded projects.

Florida: Fla. Stat. § 421.55 provides relocation assistance for persons displaced by community redevelopment activities.

New York: N.Y. Em. Dom. Proc. Law § 704 and N.Y. Pub. Hous. Law § 74 govern relocation assistance and supplemental benefits.

This template is provided for informational purposes only. Relocation benefits and deadlines vary significantly by jurisdiction and funding source. Consult a licensed attorney before filing any relocation assistance claim.