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. Total Claim and Request
10. Certification and Signature
11. 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 or assistance (if known): ☐ FHWA ☐ HUD ☐ Other: [____________] ☐ None known

Agency's written relocation eligibility determination: ☐ Attached ☐ Requested ☐ Not yet received

III. ELIGIBILITY DETERMINATION

Type of Claimant:

☐ Residential Owner-Occupant (owned and occupied for at least 90 days before negotiations — 42 U.S.C. § 4623)
☐ Residential Tenant or other eligible occupant (lawfully 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 (identify the governing relocation program)
☐ Other: [________________________________]

For a federal or federally assisted project, the agency must determine whether the move qualifies under 49 C.F.R. § 24.2(a). A state or local program may have a different coverage rule.

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: $[________________________________]

Choose actual residential moving expenses or the fixed schedule. The agency may separately approve storage under 49 C.F.R. § 24.302.

B. Business/Farm/Nonprofit Moving Expenses (49 C.F.R. §§ 24.301, 24.303, 24.304)

☐ Fixed Payment in Lieu (eligible business, farm, or nonprofit; 49 C.F.R. § 24.305)

Average annual net earnings: $[________________________________]
Fixed payment claimed (business/farm min. $1,000 / max. $53,200; nonprofit amount calculated separately under § 24.305(d)): $[________________________________]

For an eligible nonresidential claimant, the fixed payment replaces both actual moving expenses and reestablishment expenses. Do not add the two routes together. Average annual net earnings support the business/farm calculation; they are not an additional payment.

VI. REPLACEMENT HOUSING PAYMENT CLAIM

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

Federal regulatory cap: $41,200 under 49 C.F.R. § 24.401, subject to housing-of-last-resort rules. A mortgage-interest payment generally requires a bona fide lien for at least 180 days before negotiations. The owner must purchase and occupy a qualifying replacement dwelling within the applicable one-year period under § 24.401(a)(2), unless the agency extends it for good cause.

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

Federal regulatory cap: $9,570 under 49 C.F.R. § 24.402, subject to housing-of-last-resort rules. Select rental or down-payment assistance; do not add both.

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. TOTAL CLAIM AND REQUEST

Selected moving route: ☐ Actual expenses ☐ Fixed residential schedule ☐ Fixed nonresidential payment

Selected replacement-housing route, if eligible: ☐ Owner purchase ☐ Tenant rental ☐ Tenant down payment ☐ None

Total requested, counting only the selected routes: $[________________________________]

I request a written eligibility and payment determination for each selected category, payment of the approved amount, and written reasons and appeal instructions for any denied or reduced item. Do not include a payment already received under another law or insurance for the same purpose and effect (49 C.F.R. § 24.3).

X. CERTIFICATION AND SIGNATURE

I, the undersigned, certify that the information contained in this claim is true and correct to the best of my knowledge. Amounts identified as paid were actually incurred; amounts identified as estimates remain subject to supporting documentation and the agency's determination. For a federally covered claim, I will provide the certification required by 49 C.F.R. § 24.208.

Claimant Signature: [________________________________]

Printed Name: [________________________________]

Date: [__/__/____]

Prepared by (if representative):

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

XI. 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. For a federally covered claim, file a written appeal within the agency's stated period, which cannot be shorter than 60 days after written notice of its determination (49 C.F.R. § 24.10(c)).
3. Receive review by the agency head or a designee who was not directly involved in the action appealed (49 C.F.R. § 24.10(h)).
4. Seek judicial review if available after the agency's final decision; the agency must give notice of that possibility if it denies full relief (49 C.F.R. § 24.10(g)).

Federal claim-filing period: Under 49 C.F.R. § 24.207(d), a tenant must file within 18 months after displacement or temporary move. An owner has 18 months after the later of displacement or final acquisition payment. The agency must waive that period for good cause. Obtain the agency's written deadline and appeal instructions.

STATE-SPECIFIC CONSIDERATIONS

California: Ask the displacing agency to identify the applicable California relocation program, its benefit schedule, claim form, and appeal procedure.

Texas: Tex. Prop. Code § 21.046 requires a compatible relocation advisory service and specified payments when an acquisition displaces a qualifying person or organization; subsection (e) also addresses moves caused by code enforcement, rehabilitation, or demolition. Ask the agency for its implementing rules.

Florida: Fla. Stat. § 421.55 authorizes state and local relocation payments and services for public projects using federal or federal-aid funds.

New York: Ask the displacing agency which state or local relocation program applies, what benefits it offers, and how to submit and appeal a claim.

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.