CM-2018-1812 - 8/10/2018DocuSign Envelope ID: 7F43086E-D844-4DD0-B66F-D4DA83FSCE18
Farm Row -R-0
(Rev. 07111)
Page 1 of 1
CLAIM FOR ACTUAL MOVING EXPENSES
Print or ve All Information
L Name ofClaimant(s) Parcel No: 25-02 County: Williamson
Carlos Lopez
ROW CSJ: 0681-01-092 Project No.: NIA
2. Address of Property Acquired by State: 3. Address Moved To:
712 Round Rock Avc. 1308 Round hock Ave.
Round Rock, TX 78681 Round Rock, TX 78681
Claimant's Telephone No.: 512-663-6674
4. Occupancy of Property Acquired by State:
5. Distance Moved: I Miles
From (Date): To (Date of Move):
1
7. Mover's Name and Address:
2002 !August 3, 2018
Negotiated Sclf Movc
Owner/Occupant IR Tenant
6. Controlling Dates Mo. Day Yr.
a. First Offer in Negotiation
9. Amount of Claim:
a. Moving Expenses
b. Reestablishment Expenses
5
s
b. Date Property Acquired
c. Date Required to Move 8 1 3 1 2018
8. Property Storage (attach explanation)
From (Date): N/A To (Date of Move): NIA
C. Searching Expenses
d. Tangible Property Loss
$2,500.00
$
Place Stored (Name and Address):
N/A
C. Storage
f Tcmt)orary Loostinp
S
S
10. Temporary Lodging (attach explanation)
From (Date): N'A To Date of Move):NIA
g. Total Amount
S2_j;nn.nn
1 I 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 I have
not submitted E
ther claim , or received reimbursement for, an item of expense in this claim, and that I will not accept reimbursement or
compensation any oth urce for any item ofexpense paid pursuant to this claim. I further certify that all property was moved and installed at the
address shownlock 3, ve, in accordance with the invoices submitted and agreed terms of the move and that all information submitted herewith or
included herein i tru t
Claimant
Date of Claim:
- 16 -1g--
Claimant
Spaces Below to be Completed Oy State
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 reasonable expenses and this claim is recommended for payment as follows:
Amount of S 2,500.80 Docs IpW br.*
7/27/2018 _ �d,�yy,
Laurie Hadley:—city mana r
e -M-2 6/1, /r/ -,)--
DocuSign Envelope ID: 7F43086E-D844-4DD0-B66F-D4DA83F8CE18
M=
jilt..�
Form RDW -R -ISE
Rev. 5/2003
GSD -EPC
Pagc I of 2
ITINERARY FOR SEARCHING EXPENSES
Person Contacted
Date
Name
& Location
Dumber
Hours
Hourly
Totals
(Address, City, State)
of Miles
Spent
Rate
Searching
0
0i-1018
Erviqut Oiaz Lrru+tlC
,46J� W,wAw ac t)2 1m- q L
(5
$ �S
$ k
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25
'9
Zoo Q,cll IbWd CtdW+ ► L
w q69 -55
1.
,lg
"7
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I-
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S
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204 61a^ W h j W' AglJtut TY jd7aY
$5
',ZOO
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DocuSign Envelope ID: 7F43086E-D844-4DD4-B68F-D4DA83F8CE18
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1-iGreCi {� y1Z`!�'i X57 S `� S zz $ $'
IIS: 1 Ftmh 0u..ut b2o rlu� u-1 rte' lA
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03 - 0,5 —12f ~ i GF ac.in.t w�c r nv a,, ,.u. L'�c $ 15 $
Other Eligible Expenses:
'j�J�Il']iI�S e6•5W5 4&.a7 �rrn:j<s /�$� Amount:
TOTAL AMOUNT: S
I certify that the above -recorded expenses were incurred while searching for replacement property for
my business.
Name r Date: — 1
fn.lc�,cse ysit.a�
kaoucs Q1 00
-$a,g5CC4F
DocuSign Envelope Ib: 7F43086E-0844-4DDo-866F-D4DA83F8CE18
Project: RM 620
Parcel: 25-02
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 agent/broker 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: $ 0.545
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.
4Amounmbursed for time spent searching: $
Relocatee
Agent
5. 0 V,.
8 -,/25 -
Date
-,/.Date
Date
"'w"'�s�aquiwian cam
Docu$lgn Envelope ID: 7F43086E-DB44-4DDU-866F-D4DA8358CE18
P,
Farts Row.R--_'* RELOCATION ADVISORY ASSISTANCE - PARCEL RECORD
(Rev 021121
Page l ore
racce
rate Form for Each Displaced Family Unit or Busincas/Farm/Non-Profit (Print or Type All Information]
me ( nclude Spouse's Name): ROR+ CSJ: 0683-01-092
nty: Williamson
c,v.t Patrol No: 25-2Pro'ect Na.:NIA
s ( lace of isplacement)New Address:����� �4� A V -C
Phone No. t5179 (p& 3 L Cr 4 Site or Apt. No.: Phone No.:
Site or Apt. No-:
Gender: ADA Considerntinns t-R—rinl t�r�o.rr
P -Male
❑ Female
Fee Interest Before Displacement: ❑ Owner
Existing Lease
Date Signed, f O
Duration-
Lease
urationLease Amount S:
Utilities included? ❑ Yes !o
Type of Activity: Restaurant
Last two years income: Year 1: $
(S
N'A
N,`A
hite ❑ Black
L91iispanic ❑ Asian or Pacific Islander
tj American Indian/Alaskan Native ❑ Other
Fee Interest After Relocation: [I Owner 191enant
Replacement Lease
Date Signed.
)_01 Duration:
Lease Amount S:
Utilities included? ❑ Yes ❑ No
usiness, Farm or Nonnroiit Or"nl"tinn
�(I Year 2: S 2 13ei
Residential Dis laceme
etc,) Numbcr of Per
NrA
❑ Continued
El Terminated
:Rooms
otal Number of Number of Number of Bathrooms:FiOc=cuplied:
ber ofRooms Living Space (Sq, ft.)-.
in Subjcct: NIA Bedrooms: K, A M A N/A NIA
Displacec Income:
L Occupation (Where & What): 3- Other sources of eligible income:
2. Gross Last I2 Months. S 2-E;;' 4. Welfare (Source & Amounts):
The information contained within this f s being collected to allow the Agency to provide the best possible advisory services and to
help identify all possible relocation the displaccc(s) is/=eligible for. By signing below I certify, to the best ormy knowledge,
that all the foregoing information is c and accurate and that no information has been withheld or omitted.
Displaoee Signature: Date.—
Displacee Name (printed): - Title:
verification not included: Date move
Relocation Agents' Signature.(,Date: te -
Relocation Agents' Name (printed):
ThO R5 about the I Def t of Transpxwtkn maintains tha infommation mttected through Wt firm. With few
nWmation that we collect about you, Under SeCtfons 552021 and 552023 of the Govemniant Code, s' Y� ere entitled on request to be inforrrred
lnfarmatlon Under Section 55g.oW of the Government Code, you are also entitled b have us [arced infarrrmtion about also are arrNed to receive and review this
you OW is incorrect
*R96*
DocuSign Envelope ID: 7F43086E-D844-4DD0-B66F-D4DA83F8CE18
RELOCATION ADVISORY ASSISTANCE - PARCEL RECORD
Form ROW -R-96
(Rev. M/12)
Pati I ore
for
Ungmat Address (Place o
712 Round Rock Ave.
Round Rock, TX 78681
Phone No.: 512-663-6674
® Male
❑ Female
Site or ApL No.:
S ! S— aerial Need:
Fee Interest $eros Displacement: ® Owner 0 Tenant
Existing Lease
or
Parcel No: 25-2
I308 Round Rock Ave.
Round Rock, TX 78681
Phone No.:
Ethnic Code.
® White
® Hispanic
❑ American Indian/Alaskan Native
r•1
or Tj-"c All information)
tty: Williamson
xt No.: NIA
Site or ApL No.:
❑ Black
❑ Asian or Pacific Islander
❑ Other
ee merest After Relocation: Lj Owner U Tenant
Date Signed: 10/06/14 Date Signed:
Duration: April 2019 Duration:
Lease Amount S: 3,400.00 Lease Amount S:
Utilities included? ❑ Yes ®No Utilities included? ❑ Yes ❑ No
Business, Farm or Non rock Organization
Type of Activity: Restaurant
® Continuedast
Ltwo years income: Year is $ 275,341.00 - 2016 Year 2: S 287,399.00 - 2017 E] Terminated
Type of Property (Single Detached, Multi -Family, etc.) Number
N. -'A NrA
Age/Sex/Rclationship of Other Household Occupants_.
N?A
Total Number of Number of Number of Bathrooms: Number ofRooms Living Spas (SQ. R):
Rooms in Subject;. N?A Bedrooms: NIA N/A Occupied: N/A NIA
Displaces Income°
I. Occupation (Where & What): Restaurant Owner 3, Other sources ofeiigibic income: NIA
2, Gross Last 12 Months: S 287,399.00 4. Welfare (Source & Amounts): NIA
The information contained within this farm is being collected to allow the Agency to provide the best possible advisory services and to
help identify all possible relocation benefits the displacee(s) Ware eligible for. By signing below 1 certify, to the best of my knowledge,
that all the foregoing information is current and accurate and that no information has been withheld or omitted.
Displaces Signature. Dom• 06/05/18
Displaces Name (printed): Carlos LopezTitle: Owner
Reason
not
Relocation Agents' Signature:
Relocation Agents' Name (printed); Laurie Miller
Date move
Date: 06/05/18
The Texas Department of Transportation maintains the Iftrmatbn coltected through this form. Vft few
aboutexcepdona, you are entified on request
the Inf rrn011an that We t o 18d about you. Under Sections 552 021 and 552A23 of the GovemRxxmt COQe, you also are entitled to receive oto review
Information. Under 5edion 559.004 at the Goverment Code, you are also entitled to be lnkxTned
have us correct information about you that is incorrect this
*R96*
DocuSign Envelope ID: 7F43088E-D844-4DDO-866F-D4DA83FSCE18
Form ROW -R-96 (Rcv 01/12)
Page 2 oft
Date of Occupancy: Date Required to Move: Actual Date of Move: Distance of Move:
01/01/02 7-5-18 extended to 813/I8 ,
Date Notified of Availability of Relocation Payments and Assistance (Services):
Date Displacee Offered Assistance in Locating Replacement Housing or Operating Facilitv:
Name of Other Agencies Assisting in Relocation:
Date of 90 day notice:
414/17
Date of 30 day notice:
612118
Method used to verify income:
Method used to determine eligibility:
Date of initiation of
2124117
I ranslator needed?: F1 Yes
Language of displacce:
Date and Substance of Follow-up Contacts (Use extra pages ifnecessary):
July 21, 2016 - Mel with the appraiser and Attorney Dan foster to do the walk thru for the appraiser. Dan Foster said he did not wanting
us to talk to any of the tenants at this time. 1 took pictures of the restaurant.
2/24/17 - Sheets and Crossfield sent the offer letter to the owners of this parcel. I contacted the owner of the property to see if he could
give me the contact information for his tenants. 1 called and left a message on voice mail. In the mean time 1 did a search on SOS and
found out that Manual Lopez was the owner and he owned another Restaurant with the same name in Austin. 1 called and left a message
with one of the employee(who ever answered the phone). Sent emails to Don Childs letting him know that I was not able to find any other
names or addresses of the owners for the resturant and could he contact Dan Foster to give us this information. I have sent ails to M
Foster with out any response, r.
4/7/17 - Sent 90 -day letter to the address of the Restaurant in Round Rock, the certified green return receipt was signed by a Lillian Lopez.
April 7, 2017 - Sent out 90 -day letter, search SOS for owner. Sent letter to Property owner in hopes to receive a copy of the lease and
contact information.
April 7, 2017 - Stopped by the Taguerin to see if I could either talk with the owner or set up a time to meet with them. The employee said
he was not in. I left my business card and asked her to have him call me.
From April 7, 2017 to May 19, 2018 - I have called the taqueria stopped by multiple times and dropped off packets of relocation
documents for the owner of the business to fill out. I also included my business card. I never heard anything from the the owner until
May 28, 2018 when the property owner let his tenants know that now the property belonged to the state of Texas and the City of Round
Rock. Since that date Carlos Lopez and I have met and we have either talked on the phone, emailed several times a week or text
messaged.
June 1, 20I8 - Met with Carlos, his wife, his brother who is the registered agent and his wife. 1 went over the relocation benefits,
explained the searching expense and how the re-establishment works. They were not very happy that they had to be reimbursed and I
explained that they could use a Direct Payment to Vendor form where TXDOT would pay the vendors/conh=tors directly so that they did
not have to come up with the money.
June 2, 2018 - Sent the 30 -Day letter to Taqueria Chapala Jalisco #2. Vacate Date July 5, 2018.
June 4, 2018 - Stopped by the restaurant to pick up the signed relocation forms. Carlos left the documents in a folder for me to pick up.
DocuSign Envelope ID: 7F43086E-D844-4DDO-B66F-D4DA83FBCE18
a
Farm ROW -R -GE
(Rev 03/15)
?ape 1 of 1
CERTIFICATION OF ELIGIBILITY
ROW CS7: 0683-01-092
Parcel: 25-2
Displacee: Taqueria Chapala 42
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 resent in the United States, supporting documentation will be required.
7
laimant Date:
Claimant Date:
Incorporated Business, Farm or Nonprofit Organizations
I certify that I have ignature authority for this entity and such entity is lawfully incorporated under the
applicable state's 1 and authorized to conduct business within the United States.
Claimant
Date:
DocuSign Envelope 1D: 7F43086E-DB44-4DD0-866F-D4DA83FBCE18
AP -152
O " (Rev.9.17117) FZ 7 For compbVIleCa uye awy
Application for Texas Identification Number
• See instructions on back
1. Is this a new account? ROY"'ES Mail Code 000 ❑ NO Enter Mail Code
Complete Sections 1 - 5 Complete Sections 1, 2 R 5 - Agency number
2. Texas Identification Number (TTN) - Indicate the type of number you are providing to be used for your TIN
® Employer Identification Number (EIN) (9 dg+ts)
r ❑ Social Security number (SSN) (9 dohs) Enter the
e
0 ❑ Individual Taxpayer Identification NumberITIN number indicated
( ) fa digits)
U3 ❑ Complrotiees assigned number (FOR STATE AGENCY USE ONLY) (11 digits)
❑ Current Texas Identification Number (FOR STATE AGENCY USE ONLY) (11 dgts)
3. Are you currently reporting any Texas tax to the Comptroller's If "YES," enter Texas
office such as sales tax or franchise tax? Cl YES ❑ NO Taxpayer Number
Payee Information (Please type or print)
4. Nen1e of payee (Individual or business tp be peter)
t
5. Mailing address whero you went to mceiveyments
a. (0026 0
N
7. (Ophbmo
C
m
N
s. foptiona9
9. City state TIP code
C -RI .-
10. Payee telephone number
(Area code and number) .. tip , —
J
SIC Security Zone
. , code
11. Ownership Codes -Check on one code b the type code �--' (0,1, 2) code �
�' Y appropriate ownership type that applies to you or your business.
❑ I - Individual Recipient (not owning a business)
❑ L- Texas Limited Partnership:
8 - Sole Ownership (Individual owning a business): 1t checked,
If checked, enter the
Texas Re Number
enter the owner's name and Social Security number (SSN)
ElT - Texas Corporation:
Owner's name �7_ y,If
checked, enter the
--� ��
SSN 1ITIN (9 digits) I �� ; , �,
Texas He Number
❑ A- Professional Association:
If checked, enter the
A❑ P - Partnership: If checked, enter two partner's names
Texas File Number
and
u Social Security numbers (SSN). If a partner is a corporation, use
the corporation's Employer
❑ C- Professional Corporation:
Identification Number (EIN).
If checked, enter the
Texas File Number
Name
❑ O- Out-of�State Corporation
SSN 1 ITIN 1 EIN (9 dam) , _ ❑ G- Governmental Entity
Name ❑ U- Stale agency 1 University
SSN 1 ITIN I EIN (960itsJ ❑ F - Financial Institution
❑ R- Foreign (out of U.SA)
❑ N- Other. If checked, explain.
o, 12. Payment Assignment? ❑ YES ❑ NO Note: A cagy of the a
gr
c assignment agreement between payees must be attache
Assignee name
m
Assignee TIN
Assignment date I� I I r
13. Comments
n sign Auft!e° ( twautbortzedepenlJ pale
14. here, t
m
W Agency turns Phono (Mee m e -nu
15. �P� by * mbeq
DocuSign Envelope IN 7F43086E-D644-4DD0-B66F-040A83F8CE18
MEMORANDUM
July 16, 2018
TO: Sheets & Crossfield
Attn: Lisa Dworaczyk
FROM: Laurie Miller
SUBJECT: Parcel 25-02—Taqueria Chapala 2
ROW CSJ — 0683-01-092
Project: RM 620
Request Payment — Searching Expenses
Texas Department of Transportation
Austin District
Attn.: Shanna Pasemann
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 522500.00
(q) 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 (1) Signed (1) Typed
{�) Certification of Eligibility
(�) W-9 and AP -152
EXPENSE VERIFICATIONS
{') Comments: The attached packet is a Request for Reimbursement for Searching Expenses. I believe
the rate that Carlos Lopez charged for his hourly rate is reasonable based on the income taxes for
2016 & 2017 he has shown me for the restaurant. Mr. Lopez searched more than the maximum
limit on searching and he is aware that he can only be compensated for the maximum amount.
The displacce has asked if we could expedite the searching expense payment because they are need all
available funds for the renovations of the replacement site
The Austin District agreed to assist the City of Round Rock by providing primary oversight of all relocation
assistance submissionx All relocation packages are sent to Texas Department of Transportation for
approval then sent to file 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
1
' ROl1N0 ROCK
T, �f, ', Agenda Item Summary
Agenda Number:
Title: Consider approval and execution of claim forms authorizing the payment of
replacement site searching expenses in the amount of $2,500 for the
relocation of the Taqueria Chapala on the RM 620 project (Parcel 25).
Type: City Manager Item
Governing Body: City Manager Approval
Agenda Date: 8/10/2018
Dept Director: Gary Hudder
Cost: $2,500.00
Indexes: RR Transportation and Economic Development Corporation (Type B)
Attachments: 00406964.PDF, 00406946.PDF
Department: Transportation Department
Text of Legislative Fife CM -2018-1812
Consider approval and execution of claim forms authorizing the payment of replacement
site searching expenses in the amount of $2,500 for the relocation of the Taqueria
Chapala on the RM 620 project (Parcel 25).
As part of the RM620 expansion project the City purchased the Mobil gas station (Parcel
25) where Mr. Lopez had a restaurant which qualified for relocation. The Uniform
Relocation Act allows for replacement site searching expenses to be recovered as a result
of this displacement, and the requested amount is supported by the TxDoT rules and
recommended by the relocation consultant for payment. This payment is 100%
reimbursable by TxDoT in connection with the RM620 project.
Cost: $2,500
Source of Funds: RR Transportation and Economic Development Corporation
City of Round Rock Page 1 Pdinted on ON12019