CM-2018-1786 - 7/23/2018DocuSlgn Envelope ID: 8446E647-642C4AAO-851F-E7DOBF652A2D
Farm ROWR-102
pane 07of zl
f—
Applicant's Name:
Moltummed Khan
2. Applicant's Address:
712 Round Ruck Avenue
Round Rock, TX 78681
'Telephone No... 512-848-6308
4. occupancy of Property Ac
From (Date):
10/112005
i. Type Operation
Business ® varm ❑
, i D MOVING EXPENSE PAYMENT -
IESS. FARM OR NONPROFIT ORGANLZ
Print or Type All
fired by Stato
To (Date Required to Move)'.
7/3/2018
Nonprofit ❑
Type of Business, Fann or Nonprofit Organization
Convenience Store
- Read Rules on the
Parcel No.: 25-1
CS1:
Side
County: Williamson
Project No - NIA
1. Name and Address of Business, Farm or
GK Stores Inc., dba Eagle Mart Nol
712 Round Rock Ave.
Round Ruck, TX 78681
❑ Owner Occupied ® Tenant Occupied
Will Business, Farm, or Nonprofit be: Yes
No
a, Discontinucd7
®
a
b, Continued at a now localiaal
❑
C. Ire business or nonptofrtorgnalzotion, is it part
of an enterprise having not more than three (3)
other ertrbti+hmeuls: belug+tcgnircd by the Stutc, y
Dates of O :rationf''311F:'=tt ({(i �li , t. '�1-&=I T-�;; :,ue}j s tt tt, l ` s �t !,--j
F i:iii t t ' 1 , ]&_
From:
3117/10 Present .,17
b. Determination of entitlement for payment in lieu of moving:>;pense and the amount to which the business, farm or nonprofit
organiuttion natncd above may be entitled to, if any, is requested for the reason(s) outlined in the attached statement. I understand this
ri:qucst and the attached documents shall become part of any claim fur payment; and that other records needed d Curd rein i true
a of
eligibility shat! be made available on request of the State. I certify that all infortna 'on attached i reto or included Ltcreitt is tine and
correct.
5ignatute or Applicata
AG -2Y -/S --
to
state
ng
I cstrtiFy that I have examined the records made aveilab y theAverA a Annual aNet Larningr) and have aS El tn6itl~
2016,—5b9;46� 9@;
.641-
2017, -95�1;6d1.00, g
Yeark/ 3, y13,od Year y 51191.4
"?, -- L�w�p y rG
Right of Wa
ie os fallows; t^
y`/r 362. ao
Dale
I certify that I have examined this request for Determination of Entitlement and supporting documentation and:
® ltoconimend a payment of 540,000.00 .
Find that payment cannot bo authorized because
(List reasons payment cannot be authorized, Use cxlra page "��� nod by:
7/10/2018 (+C,�t-
en]aFBEWE13428
Date
p oved by1L[i y Manage
/ �,GLLCer.'J'f�
J f wl t Cf JM -C
�'1v(,—P tf (� �� *R102*
Docu5ign Envelope ID B446E647-602C4AAO-65tF-E70aBFe52A20
Form ROw•R•101
(Rev. 07111)
pap 1 of 1
CLAIM FOR PAYMENT FIXED MOVING EXPENSE -
BUSINESS, FARM OR NONPROFIT ORGANIZATION
Print or Type
All Information
1. Applicant's Name:
Parcel No.: 25-1
County: Williamson
Mohammed Minn
ROW CSI: 0683 -OL -092
Project No,: NIA
2. Applicant's Address:
3. Name and Address of Business, Farm or Nonprofit Organization,
712 Routed Ruck Avenue
GK Stores Inc., dba Engle Mart Not
Round Ruck, TX 786811
712 Round Rock Ave.
Telephone No.: 512-848-6308
Round Rock, TX 78681
4. Address Moved To (If Applicable):
5. Controlling Date
Mo. Day
yr
T13D
a. First Offer in Negoliations
2 24
2017
b. Date Property Acquired
5 31
2018
c. Dale Acquired Property Vacated
d. Dale Required to Move
7 3
2018
6. Amount of Claim S 40,000.00
7. Payment of this claim in the amount shown in Block 6 above is requested, I cerlify that 1 am the owner or authorized representative of
The business, farm or nonprofit organization named nbave. I undersltrnd this claim for payment is baked upon information pea% iously
submitted to the Texas Department of Transporlation and that aJl such W ommtion is true and correct and part of this clairu l liuther
certify that 1 have not submitted any claim for, or received reimbursement or compensation for, any item of expense in this claim, and
that f wi I I not accept reimbursement or compensation from any other source for any item of expense paid pursuant to this claim.
By:
Applicant's Signature
{'
l fr'-s:0f."i /Ioudc&---
bfi a2 ?` 6,zt,
-
Date of Claim Tille or Position (Owner, Manager, Etc.
Space Below to be Completed by State
I certify that l have examined this claim and the Request for Determination of Entitlement and have found it to be true and correct and to
conform whit tho applicable provisions of Slate law. This claim is recommended for paymoul.
1�by:
CVDOCUSIgnsco
7/10/2018 A%IU CIaVY'dLl.
—
Date 9DMF9EaaE13420 1 or way Manager
'R101'
DocuSign Envelope ID B446E647-692C4AAo•851F-E7DOBF652A20
MEMORANDUM
February 22, 2018
TO: Sheets & Crossfield Texas Department of Transportation
Attn: Lisa Dworaczyk Austin District
Attu.: Shanna Pasemann
FROM: Laurie Miller
SUBJECT: Parcel 25- Mohammed H. Khan - Eagle Mart No I (Mobil Station)
ROW CSJ - 0683-01-092
Project: RM 620
Request Approval & Payment - Fixed In Lieu of Payment
It is requested that the attached submission for be handled on a normal basis. In, support of this request,
please find the following:
(4) Letter From Displacce requesting a Fixed -In-Lieu Move
(4) Fixed Payment Calculation Sheet
(J) Form ROW -11-101, Claim for Payment Fixed Moving Expense - Business, Farm or
Nonprofit Organization
(4) Form ROW -R-102 - Fixed Moving Expense Payment - Business, Farm or Nonprofit
Organization
(4) Copies of 2016 and 2017 Tax Returns (Certified by CPA)
(4) Certification of Eligibility
(4) Move Plan
(4) Form ROW -R-96 Relocation Advisory Assistance - Parcel Record
(4) Certified Inventory of Personality (Photo Inventory)
(d) W-9 & AP 152
(4) Displacee's Lease from Acquisition Site
EXPENSE VERIFICATIONS
(�) Comments: The attncl:cd packet is a Request for approval and payment for the Fixed In -Lieu
of Package.
The Austin District agreed to assist the Clty of Round Rack by provirling priniftly oversight of rill
relocation assistance submissions. All relocation packages are sent to Tetas Departrneril of
Transportation for approval then sent to the City of Round Rock for payruent.Signature lilies for
approval ivlll reflect this process
We approve and recommend that the allached submission be processed at your earliest convenience. If
additional information is needed, please contact Laurie Miller of this office at (512) 413-401
Laurie Miller, R/W-NAC, R/W-URAC
Attachment
cc:
Laurie Miller, WW -RAC, R/W-LT AC 512-4134012 110 Jacobs Way, Hutto, TX 78634
DocuSign Envelope ID. B44BE647-692C-4AAO-861F-E7DOBF652A2D
hute 15. 2018
Texas Department of Transportation
City of Round Roel:, Texas
Re; Fixed payment (In Lieu)
Dear Texas Department of Transpartation;
On behalf of Eagle Mart No. l (GK Stores Inc — Pam -el 25)1 could like to make an application for fixed
payment in lieu of itemized expenses. Please review my application for the relocation. The following
statements are applicable to this application as noted from the Relocation Assistance Booklet.
• Eagle Mart No. I owns personal property which be moved in connection with this displacement
and expenses will be incurred.
• Eagle Mart No. l cannot be relocated without a substantial loss incurred in its operations.
• Eagle Mart No. 1 is not pan of a commercial enterprise having more than three other entities not
being acquired and which are under the same ownership and engaged in the same or similar
business aceivities.
Eagle Mart No. 1 is not operated at a displacement d%velling solely for the purpose of renting such
dwellings to others.
* Eagle -Mart No. I is not operated at a displacement site solely for the purpose of renting the site to
others.
Eagle Mart No. i contributed to the income of the displaced person Bilai Malin during the two (2)
taxable years' prior to displacement_
For these reasons, l atn requesting a fixed payment in lieu of actual moving expenses due to the relocation
of my business. ifyout need any more infottnation, please do not hea`itate to call me at 512. g eig — 6 3 O k
Thank your for taldng rite time to review my application
Sincerely,
Mobammcd Khan
Eays, le Mart No. 1
CG r-, 5 qg -43v '?,
DocuSlgn Envelope ID: 8446E647-692C-4AA4-851F-E700OF652A2D
Fixed Payment In Lieu
Displaced Business: GK Stores Inc., Eagle Mart No.1
CSf Account: 0683-01-092
Parcel: 25
Calculation of Fixed Payment For Moving Expenses-- Nonresidential Payment In -Lieu:
Year: 2016
1. Net Income or (Loss) $13,313,00
2. Compensation Paid to Owner $ 30,100.00
{Not applicable for Corporations}
3. Wages Paid to Spouse and/or Dependents $ 0.00
{Not applicable for Corporations}
4. NET EARNINGS FOR YEAR $ 43,413.00
{Total of Lines 1-3}
Year: 2017
S. Net Income or (Loss) $12,541.00
6. Compensation Paid to Owner $ 32,650.00
{Not applicable for Corporations}
7. Wages paid to Spouse and/or Dependents $ 0.00
{Nat applicable for Corporations}
8. NET EARNINGS FOR YEAR $ 45,191.00
{Total of Lines 5-7}
9. TOTAL NET EARNINGS $ 88,604.00
(Add Lines 4 & 8)
10. AVERAGE ANNUAL NET EARNINGS $ 44,302.00
{Line 9 X .50}
11. FIXED PAYMENT AMOUNT $ 40,000.00
The maximum allowable Fixed Payment in Lieu of Moving Expenses is $40,000.00.
All personal property must be moved from the subject property before payment is made.
City of Round Rock
i ROUNt] ROCK
TEXAS Agenda Item Summary
Agenda Number:
Title: Consider execution of claim forms approving and authorizing payment of a
fixed moving expense in the amount of $40,000 for the GK Stores, Inc., dba
Eagle Mart No. 1 due to displacement of the business caused by acquisition
of right of way on the RM 620 project (Parcel 25).
Type: City Manager Item
Governing Body: City Manager Approval
Agenda Date: 7/20/2018
Dept Director: Gary Hudder
Cost: $40,000.00
Indexes: RR Transportation and Economic Development Corporation (Type B)
Attachments: 00405462. PDF
Department: Transportation Department
Text of Legislative Fife CM -2018-1786
Consider execution of claim forms approving and authorizing payment of a fixed moving
expense in the amount of $40,000 for the GK Stores, Inc., dba Eagle Mart No. 1 due to
displacement of the business caused by acquisition of right of way on the RM 620 project
(Parcel 25).
The maximum allowable Fixed Payment in Lieu of Moving Expenses is $40,000. This is
expected to be the only relocation claim expense for this tenant. This payment is 100%
reimbursable by TxDoT in connection with the RM620 project.
Cost: $40,000
Source of Funds: RR Transportation and Economic Development Corporation
City o/ Round Rock Page 1 Printed on 7/49/2018