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CM-2018-1658 - 3/9/2018j:iF .. Form Row -R-99 (Rev. 07111) Page 1 of 1 CLAIM FOR ACTUAL MOVING EXPENSES Print or T1pe All Information 1. Nume of Cluimant(s) Parcel No: County: Williamson William Montreuil ROW CSJ: 0683-01-092 Project No.: Residence ® Business Farm LJ Nonprofit ❑ Sign El Other 2. Address of Property Acquired by State: 3. Address Moved To: 90I Round Rock Ave., STE IO2. Round Rock, TX 78681 1050 Meadow Drive 11306, Round Rock, TX 78681 Claimant's Telephone No.: 512-246-9080 4. Occupancy of Property Acquired by State: 5. Distance Movcd: Less than I R1ile From (Date): To (Date of Move): 1 7. Mover's Name and Address: 12/01/2000 I11312017 Owncr/Oecu ant 0 Tenant 6. Controlling Dates Mo. Day Yr. EL first Ofler in Negotiation 9. Amount of Claim: a. Moving Expenses b. Reestablishment Expenses $ $ b. Date Property Acquired c. Date Required to Move 8. Property Storage (attach explanation) From (Date): NIA To (Date of Move): NIA c. Searching Expenses d. Tangible Property Loss S2,500.00 S Place Stored (Name and Address): NIA e. Storage f. Temporary Lodging $ 10. Temporary Lodging (attach explanation) From (Date): NIA To (Date of Move):N/A g. Total Amount S2400.00 11. All amounts shown in Block 9 were necessary and reasonable and arc supported by attached receipts. Pay of this claim is requested. I certify that 1 have not submitted any other claim for, or received reimbursement for, an item of expense in this clam, and that I will not accept reimbursement or compensation from any other source for any item of expense paid pursuant to this claim_ I further certify that all property was moved and installed at the address shown in Block 3, above, in accordance with the invoices submitted and agreed terms of the move and dim all information submitted herewith or included hereinis true and correct. Claimant Datc of claim: Claimant _ Spaces Below to be Completed b State/Ci . of Round Rock I certify that 1 have examined this claim and substantiating documentation attached herewith, and have found it to be true and correct and to conform with the applicable provisions of State law All items are considered to be necessary reason"expenses and this claim is recommended for payment us follows. Amount of 2,500.00] Date —R—Fh—tZf Way M er Project: RM 620 Parcel: SEARCHING FOR REPLACEMENT LOCATION Your cost may be reimbursed for reasonable expenses in searching for a replacement site, not exceeding $2,500.00. Expenses may include those for transportation, meals, lodging, and the reasonable value of time spent in the search. Real estate agenttbroker search fees are eligible, but a broker's real estate fee is not. RECEIPTED BILLS Paid receipted bills must support all expenses claimed, except the displacee's search time. When a displaced business or business owner's vehicle is used and receipts for transportation expenses are not available, transportation expenses may be supported by miles traveled. Amount reimbursed for mileage: $ 0.53 TIME SPENT Payment for search time must be based on reasonable earnings for the search person. A signed form ROW - R -ISE (Itinerary for Searching Expenses), must accompany the claim. Amount reimbursed for time spent searching: $ �/,5. 66 hr. L-, K, � X- -; 4 Relocate .N A L�z /f Date ,rq - a -Z8' Date Form ROW -R -ISE Rev. 512003 GSD -RPC Page i of I ITINERARY FOR SEARCHING EXPENSES I certify that the above -recorded expenses were incurred while searching for replacement property for my business. F,V, Date: zG Name Person Contacted Date Name & Location Number Hours Hourly Totals (Address, City, State) of Miles Spent Rate Searching a? !! ifs — 'Dr. Goads,N 3Z3 Lnlct C14 -tic Cruz r���• " * $ 7` J` $ 1 1baLei) 4116 m�.lk pY. vi S.� , is eY}t•,.er.enP9 x Z , S S j1"AOIwst. oy��rore co+7}rac'?or uisrls 2-A0 /I r. D n. Rol ac 4- VmQc rt+ cLtn,r^L o Fh�-t. o- L.n,le, eti r."I '- . L' $ y $ y s s 3 ch -91! 6 rhr�c�,�h � 5ct..eh 3rd��ic o -FV..& snR e. Czf !-ri re nt 2 "' , S U $ $1H ! 6 qDo V--2 R V a- $ $ r- r% - 5 PC, L.e (i 9 20 se F{ rr U, i3 !te hY+ec.ti� h a�z,r.� t 3 2-o -_ - 35 �.>,,� 45 � z hH,los�n F.• 17unikaS:L 1 . 116 CZ -0Q, -�' " aU- 2,-,.63 ys $ I I& D �. !►m, tLV- ft aOX) Mat A � $ $ 'J 1 b h^rycr i� -PLA vcnt•s tto� o f,"s 1�-. a+rte s'h: S jj G V11%164 scif 'D - . lc.¢ ,+ h t c>tia S e ry 'jos L-; 6, �Q� 1 n. 4 x IO 3 d $ y� S Cr 13SS►.� Mn u� pl%tr-a cc.tls, tr... ' 1, $ $ it t 3 V;,=ka n i UAC11�5 uc SCLS w keK 5 a 7 C'+ h a • . +T g„c-* pr�cx"� +i %14;1.5k ate..-!: + letvY4 1C>50 Ttico+CAewS D".ve, IMS: Li //�. S,J r "r -r -W 44- l._I aly b= ps&%K-+ SLA -'-Lb �aYAt nLir.%A,c..s p1'kC--k �,o:4 and iita'3 ro hf! &I-6et, IV•'1k01 JL )it) l D �� $(� 5 S P—'MX 5-n Pba55 5 Is Other Eligible Expenses: Rca-++ 6 , !ry-�-� Cric•�:c, Cikr+.wx 2r. Amount: $ TOTAL AMOUNT: $ , I certify that the above -recorded expenses were incurred while searching for replacement property for my business. F,V, Date: zG Name Form ROW -R -CE (Rev 03116) Page 7 or 1 CERTIFICATION OF ELIGIBILITY ROW CSJ: dto8-6-Ol _pq-� Parcel: Displacee: w;//, rhanTrcu� j Individuals, Families and Unincorporated Businesses or Farming Operations I certify that myself and any other party(ies) with a financial interest in this relocation assistance claim are either: Citizens or Nationals of the United States or ❑ Aliens lawfully present in the United States * If an Alien lawfully present in the United States, supporting documentation will be required. Date: Claimant Date: Claimant Incorporated Business, Farm or Nonprofit Organizations I certify that I have signature authority for this entity and such entity is lawfully incorporated under the applicable state's laws and authorized to conduct business within the United States. Date: �d W lairnant ';.. Form Row -R•96 (Rcv.02112) Page 1 of 2 RELOCATION ADVISORY ASSISTANCE - PARCEL RECORD 6 GO 1 1&—rd Roc le- AW #102. Phone No^ci R,, -k, 7k 79691 _ p Site or Apt. No.jc Gender: ADA Considerations / Special Needs [tale ❑ Female Fee Interest Before Displacement: Date Signed: %Z_- / Duration: Lease Amount S: Utilities included? ❑ Yes Type of Activity: &^-"q1 1 Last two years income: Year 1: $ of %4 Unit or BeAness/Farm/Non-Profit (Print or a All It - Row CSS: p1o83ai- apCounty: Parcel No: I Proiect No.: A X10"d 2a,k, 75, 73611 PhoncNo.:,�, aeA- q0d0 Site or Apt. No-:,Sog Ethn' Codc: White ❑ BIack ❑ Hispanic ❑ Asian or Pacific Islander ❑ American Indian/Alaskan Native ❑ Other ❑ Owner Tenant Fee Interest After Relocation: ❑ Owner ZTeriant Lease _ Replacement Lease Date Signed: Q Mrn y'/1 Duration:41 �- �Oft Lease Amount S: / 699d 0 Utilities included? ❑ Yes i -0 Business, Farm or Nonprofit Orzanization 'Continued C�.y ens Year 2: S 61LI, pp ❑ Terminated ctc.) Total Number of Number of Number of Bathrooms: Number of Rooms Living Space (Sq, fl.)- Rooms in Subject: �k Bedrooms: Yt] 6 occupied: Displacee Income: I. Occupation (Where & What): 3. Other sources of eligible income: 2. Gross Last 12 Months: S 4, Welfare (Source & Amounts): The information contained within this form is being collected to allow the Agency to provide the best possible advisory services and to help identify all possible relocation benefits tate displaoee(s) is/are eligible for. By signing below I certify, to the best of my knowledge, that all the foregoing information is current and accurate d that no information has been withheld or omitted. Displacee Signature: Ly� Doe: Displacee Name (printed): Title, 611A111 -ox Relocation Arent Use Oniv tsp acee verification not included: Date move Relocation Agents' Signature:%Zp f -_ Dom- _ Relocation Agents' Name (printed): t,G+.rfii The Texas Department of Transportation mainte ps the informetien collected through this form. Vltith few exceptions, you are entitled on request to be Informed about the Intarmatlon that we collect about you. Under Sections 552.021 and 552023 of the Govemmenl Code, you also are entitled to receive and review Otis Information. Under Section 559.004 orthe Goverment Code, you are also entitled to have us wmect information about you that is incorrect. *R96* rarrri ROW -R-96 (RN. ot; ia) Page 2 of 2 Relocation A Cnt UsC Only (continued) Date ofOccupancy: Date Required to Move: 1 Actual Date of Move: 1 Distance of Move: 12/01/06 102017 10-21-17 thru 11-3-2017 0.5 Miles Date Notified of Availability of Relocation Payments and Assistance (Services): Date Displacce Offered Assistance in locating Replacement Housing or Operating Facility: Name of Other Agencies Assisting in Relocation: NIA Date oF90 day notice: Method used to determine eligibility: Date of 30 day notice: Date of initiation of negotiations: Method used to verify income: 'I ranslator needed?: ❑ Yes ® No Language ofdisplueec: English Date and Substance of Follow-up Contacts (Use extra pages if necessary): 1125118 - Received phone call from Dr. Montreuil, we set up an appointment for Friday, January 26, 2018 at 10:00 am. 126/18 - I met with Dr. Montreuil at his new replacement office approx. a half a mile a way from his old office on RM 620. 1 explained the relocation program and benefits and gave Dr. Montreuil a Relocation Brochure. We went through all of the telo paperwork and Dr, Montreuil signed all the necessary documents. We then began to go over receipts and invoices that he had and discussed if they they would be reimbursable and 1 told him the majority of them are and that there may be some that are not but I will not know for sure until I am able to sit down and sort everything out and put everything into a spreadsheet. Some of the items we went over still needed some back up documents so Dr. Montreuil and I agreed to meet again next Saturday, February 3, 2018, same time and place to go over his searching expenses and back up documents and to receive the last of the receipts, canceled checks and invoices. 2132018 - Met with Dr. Montreuil, we went over the back up documents for his searching expenses and the additional invoices, canceled checks and receipts. We discussed how long all of this would take and I told the Doctor that it would take a few days for me to go through everything and sort it out, put into a spread sheet and assemble all the back up documents and then 1 would submit to City and TXDOT for approval; I told him I really could not give him a time line and he said he understood. I did say that I would submit the searching expenses first so so that he could have some money coming back soon. He was happy to hear that. 214118 - Dr. Montreuil exchanged a few text messages about some of the dates he had. I prepared the claim form for searching and sent to Dr. Montreuil for his signature. 219/19 - I contacted Dr. Montreuil about his claim form and he said that he had emailed it to me but i told him i did not receive would he mind resending it. He did later that afternoon. f;. W-9 (Rev. November 2017) pepartment of the Treasrxy Inlensal Revenue Sev$ce a�! Request for Taxpayer Identification Number and Certification ► Go to www.1mgov1FbrmM for instructions and the latest Information. is anown on your income sax rew J Montreuil DDS PA a name/disregarded entity name. Dental Health Center of on 3 Check appropriate box for federal tax classification of the person whose name is entered on rine 1. Check only one of the following seven boxes. ❑ Individuallsote prisprietor or ❑ C Corporation 0 S Corporation ❑ Partnership ❑ Trustlestete singia-member U.0 ❑ Limited liability company. Enter the tax classification (C -C corporation, S -S corporation, P.PaRnwship) IP Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not Check LLC If the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a sing$& -member LLC tha is disregarded from the owner should check the appropriate box for the tax classification of its owner. jJ Other (see instnretions) ► 5 Address (number, street, and apt, or state, account Enter your TIN in the appropriate box. The TIN provided must match the name given on line i to avoid backup withholding. For individuals, this Is generally your social security number (SSM. however, for a resident alien, sole proprietor, or disregarded entity, see the Instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see Now to get a TIN, later. Note: It the account is In more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Under penalties of perjury, I certify that: or Give Form to the requester. Do not send to the IRS. 4 Exemptions (codes apply only to certain entities. not Indivduals; see instructions on page 3); Exempt payee code (it any) Exemption from FATCA reporting code (if any) &PFS mrmntsnWwYrdDun%&0WU'W number ©©M©M0"000 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2.1 am not subject to backup withholding because: (a)1 am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding: and 3. l am a U.S. citizen or other U.S. person (defined betow); and 4. The FATCA codes) entered on this form (f any) indicating that l am exempt from FATCA reporting is correct. Certification instructions. You must crass out Rem 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends an your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributloms to an individual retirement arrangement ORA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. 1t9n I !Signature of Here l u.S. penton ► Genera! Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and its Instructions, such as legislation enacted after they were published, go to wwwJmgov1FarmW9. Purpose of Form An individual or entity (Fort W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSM, Individual taxpayer Identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIM, to report on an Information return the amount paid to you, or other amount reportable on an information return. Examples of infoin alion returns include, but are not limited to, the following. • Form 1099 -INT Qnterest earned or paid) pate 10 ZC►C./itf • Form 1099 -DIV (dividends, including those from status or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund safes and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only If you are a U.S. person (ncluding a resident alien), to provide your correct TIN. If you do not return Form W-9 to lite requester with a 77N, you might be subject to backup withholding. See What is backup withholding, later Cat. No. 10231X Form W-9 (Rev. 11-201T MEMORANDUM February 16, 2018 TO: Sheets & Crossfield Texas Department of Transportation Attn: Lisa Dworaczyk Austin District Attn.: Shanna Pasemann FROM: Laurie Miller SUBJECT: Parcel — Dr. William Montreuil ROW CSJ — 0683-01-092 Project: RM 620 Request Payment— Searching Expenses It is requested that the attached submission for be handled on a normal basis. In support of this request, please find the following: (4) Payment Request in the amount (s) of $2,500.00 (J) Form ROW -R-99, Claim for Actual Moving Expenses (4) Form ROW -R -ISE — Itinerary for Searching Expenses {�) Form ROW -R-96 — Relocation Advisory Assistance — Parcel Record {�) Certification of Eligibility (�) W-9 EXPENSE VERIFICATIONS (�) Comments: The attached packet is a Request for Reimbursement for Searching Expenses for Dr. William Montreuil. I believe the rate that Dr. Montreuil charged for his hourly rate is reasonable. Dr. Montreuil searched more than the maximum limit on searching and he is aware that he can only be compensated for the maximum amount. The Austin District agreed to assist the City of Round Rock by providing primary oversight of all relocation assistance submissions All relocation packages are sent to Texas Department of Transportation for approval then sent to the City of Round Rock for payment Signature lines for approval will reflect this process We approve and recommend that the attached submission be processed at your earliest convenience. If additional information is needed, please contact Laurie Miller of this office at (512) 4134012. Laurie Miller, R/W-NAC, R/W-URAC cc: Attachments City of Round Rock r ROUND ROCK T n, Agenda Item Summary Agenda Number: Title: Consider approval of a Claim for Payment of Searching Expenses for the relocation of his dental office on the RM 620 project. Type: City Manager Item Governing Body: City Manager Approval Agenda Date: 3/9/2018 Dept Director: Gary Hudder Cost: $2,500.00 Indexes: RR Transportation and Economic Development Corporation (Type B) Attachments: 00396960.PDF, 00396958.PDF Department: Transportation Department Text of Legislative File CM -2018-1658 Consider approval of a Claim for Payment of Searching Expenses for the relocation of his dental office on the RM 620 project. The City purchased the Commons office park where Dr. Montreuil had a dentist office that was approved for relocation. The Uniform Relocation act allows for searching expenses to be recovered as a result of this displacement, and the requested amount is supported by the rules and recommended by the relocation consultant for payment. The City has agreed with TxDoT to be responsible for the first $75K of relocation expense claims from this particular tenant. This is the first expense claim to be submitted. Cost: $2,500.00 Source of Funds: RR Transportation and Economic Development Corporation city orRound Reck Pepe r Printed on 3/8/7018