CM-2018-1811 - 8/10/2018e
Form ROW -R-99
(Rev 07111)
Page 1 of 1
CLAIM FOR ACTUAL MOVING EXPENSES
Print or Type
All Information
1. Name of Claimant(s)
Parcel No: 25-02
County: Williamson
Carlos Lopez
ROW CSJ: 0681-01-092
Project No.: NIA
Residence Z Business C3 Farm
❑ Nonprofit ❑ Sin El Other
2. Address of Property Acquired by State:
3. Address Moved To:
712 Round Rack Ave.
1308 Round Rock Ave.
Round Rock, TX 78681
Round Rock, TX 78681
Claimant's Telephone No.- 512-663-6674
.1. Occupancy of Property Acquired by State:
5. Distance Moved: l Miles
7. Mover's Name and Address:
From (Date): To (Date of Move):
1
2002 August 3, 2018
Owncr/Occu ant INATenant
6. Controlling Dates
Mo. Ray
Yr.
a. first Offer In Negotiation
2 24
17
9. Amount of Claim:
a. Moving Expenses
b. Reestablishment Expenses
53,666.00
5
b. Date Property Acquired
6 30
lg
c- Date Required to Move
8 3
2018
8. Property Storage (attach explanation)
1:rom (Date): NIA To (Date of Move): NIA
c. Searching Expenses
d. Tangible Property Loss
S
$
Place Stored (Name and Address):
NIA
C. Storage
f, Tcmpomry Lodging
5
S
10. Temporary Lodging (attach explanation)
From (Date): NfA To (Date of Move):N/A
g. Total Amount
$3,666.00
11. All amounts shown in Block 9 were necessary and reasonable and arc supported by attached receipts. Pay of this claim is requested. l ccrtiry that I have
not submilled any other claim for, or rccc •ed reimbursement for, an item of expense in this claim, and that I will not accept reimbursement or
compensation from any other source f ty item of expense paid pursuant to this claim 1 further certify that all property was moved and installed at the
address shown in Block 3, above, i rdancc with the invoices submitted
and agreed terms of the move and that all information submitted hemwnh or
included herein is true and co c
Claimant -� � -i
--
Date of Claim
Claimant
Spaces Below to be Completed by State
I certify that 1 have examined this claim and substantiating documentation attached hcrc%vok and have found it to be true and correct and to conform with
the appitcabte provisions of State law All items are considered to be necessary reasonable expenses and this claim is recommended for payment as follows:
Amount ors 3,666.00
- T - Date - - — —
— - Right of Way Manager
clly)-2otPirl�
Laurie Hadley- ity Man er
f--16 -( 111111111
* R 9 9 *
Idle undersigned displacce hereby agrees that payment for relocation services identified on the attached
scope of work will be made to Gold Triangle Company LLC. ]'his agreement is void N%ithout a signed
scope of work attached. The 'Texas Department of Transportation reserves the right and responsibility of
detennining the "reasonable and necessary" charges for the move as is customary in the industry. Carlos
Loper, understands anything not included in the attached scope of Neork must be pre -approved by
TxDOT in order to ensure its eligibility for reimbursement. Vendor understands that the Texas
Department of Transportation will not be able: to male any reimbursements for the pre -approved scope
of services until displace authorizes release oftite payment.
Displaccc's SipnaWc Datc
C L
l)ispiacee's Name (PnmcdI
Vendor's Signature Dalt
Vendor's Namc Olrintadl
'l.,(D(Yl' Project Manager Sigttatwe
IM)M` Project Manager Name (Printed)
Date
111LIJ-111
M»
Form Raw-R-DPV
{10111)
Reptnoes Form ROW R-0PT.t
Papa I cl I
AGRt;fal•IENT FOR U imcr PAYMENT TO V1,XD0lt
County:
Williamson
ROW CSJ:
0681-01-092
Highway.
RM 620
Parcel:
25-02
Idle undersigned displacce hereby agrees that payment for relocation services identified on the attached
scope of work will be made to Gold Triangle Company LLC. ]'his agreement is void N%ithout a signed
scope of work attached. The 'Texas Department of Transportation reserves the right and responsibility of
detennining the "reasonable and necessary" charges for the move as is customary in the industry. Carlos
Loper, understands anything not included in the attached scope of Neork must be pre -approved by
TxDOT in order to ensure its eligibility for reimbursement. Vendor understands that the Texas
Department of Transportation will not be able: to male any reimbursements for the pre -approved scope
of services until displace authorizes release oftite payment.
Displaccc's SipnaWc Datc
C L
l)ispiacee's Name (PnmcdI
Vendor's Signature Dalt
Vendor's Namc Olrintadl
'l.,(D(Yl' Project Manager Sigttatwe
IM)M` Project Manager Name (Printed)
Date
111LIJ-111
1
Form ROW -R -CE
;Rev 03116j
Page 1 of 1
CERTIFICATION OF ELIGIBILITY
ROW CS1: 0683-01-092
Parcel: 25-2
Displacee: Taqueria Chapala ##2
Individuals, Families and Unincorporated Businesses or Farming Operations
1 certify that myself and any other party(ies) with a financial interest in this relocation assistance claim
are either:
Ef 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.
Date: S
'laimant
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 1 and authorized to conduct business within the United States.
Date:
Claimant
Ar
' rftt:.o1]c 01 tc
For Carnprrakti's use only
TEXAS APPLICATION FOR PAYEE IDENTIFICATION NUMBER
- Shaded areas for state agoncy trot: only • Sec insfrucGuns art back-
ack1.
1.Is this anew account? EXYES Mail Code 000 NO Enter Mail Code i I Agency number
r..—r
Complete Sections I - V Complete Sections 1, II d V
2. PAYEE IDENTIFICATION NUMBER JPIN) - Indicate the type of number you are providing to be used for your PIN
1 - Federal Employer's Identification IFEI) Number
Q n.` y `� $ 5 -�
0
2 - Social Security Number (SSN) Enter the number indicated _� _�
�j
3 - Comptroller's assigned number
11w1
3. Are you currently reporting any Texas tax to the Comptroller's office other than unemployment Ie.g.. sales lax, franchise tax)?
YES NO If "YES." enter Texas Taxpayer number. ........
PAYEE INFORMATION {Please type orprfn1)
4 Mime or payee hndrvitival of husiness it- tie pits i
COLD TRIANGLE LLC..._
s 7., hng ildrIIW whcie you wanl to rw_[ vc payrnrnly
a f0p6unrnn
z
u
i
1
9 City State ZIP cwde
AUSTIN l T � �. S � 2 ._- . r zone code
____--------- ---� iXJ r. L� 1....
6.
Pa ee lel . rte number wr -
I.5--L-I—,.-2J / -L. 7j-6 9 5.
SIC Code I_ 1... r r . r
Security type rade --.I (0, 1, 2) {Titan code acrd raanherf _] _'
11. OWNERSHIP CODES - Check only en coda by the appropriate ownership type that applies to you or your business.
Q I - Individual Recipient Inot owning a business) L-1 J - Joint Venture
Ix- - State Employee II checked, II U L - Limited Partnership If checked, enter the Texas
enter employing agency number._....... {__I_._7.—
File Number
n 5 - Sole Ownership (Individual owning d business) If checked, r-- .1.� t---�•--�---
enter the owners name and Social Security Number (SSN) T- Texas Corporation It checked, enter the Texas
Owner's name _� _�.— —_ _ _ Chaner NumberL(] $ ] , 7 , 4 ] $
,
SSN
M A • Professional Association 11 checked, enter the Texas
P - Partnership If checked, enter two partner's names I
Charter Number
and Social Security Numbers (SSN).1f a partner is a
UIdentification
corporation, use the corporation's Federal Employer's
® C- Professional Corporation If the Texas
(FET) Number. checked, enter
w
y
Charter Number
SSN!FEI,.._.....)_.1_--
LI
-..
n O. Out -of -State Corporation
Name —
r••-- U G- Governmental Entity
SSNIFEI t----�� i t — . t
U • 51a1e agency +University
Name
F - Financial Institution
Type of service provided
R- Foreign lout of U S A )
-' _ —
N -Other If checked. explain.
12 Payment Assignment? 0 YES [ ] NO Note: A copy of the assrynntent agreement bofwaan payees must be attached.
z-
O
F
Assignee name
w
0
Assignee PIN —�. tr.iuj Assignment date L.- , I L_t.-..J
a
13 Comments
z
Ut'nfIW J4ir4NIrV1 nyarl _.--�� —. �••_
_--_ 1ALrli1r11+j,i,l!WrO sign
ore
w—
N
Ayeney noru Ptryurrel t+y PNW47 fatt•x ren-orlrf ntrmbaO
15,
MEMORANDUM
July 31, 2018
TO: Sheets & Crossfield
Attn: Lisa Dworaczyk
FROM: Laurie Miller
SUBJECT: Parcel 25-02 — Taquerin Chapala 2
ROW CSJ — 0683-01-092
Project: RM 620
Texas Department of Transportation
Austin District
Attn.: Shanna Posemann
Direct Payment to Vendor -Partial Payment Request of $3,666.00 — Gold Triangle
Company LLC
It is requested that the attached submission for be handled on a normal basis. In support of this request, please
find the following:
(J) Payment Reuuest in the amount (s) of $3.666.09 for disconnect and reconnect at replacement site
and reinstall the fire system — Under Moving Cost. The remaining balance of invoice will be paid
once the reinstallation job is completed. The remaining balance Is $7,334.00.
(4) Pictures of Hood and Walk in cooler
(4) Certification of Eligibility
(J) W-9 and AP -152
EXPENSE VERIFICATIONS
(� } Comments: This is a Request for Direct Payment to Vendor (Partial Payment). This request is a
partial payment to this Vendor because the Vendor has only completed a part of the job that was
estimated and approved. Once Taqueria Chapala has received their permits and the utilities are
turned on and Golden Triangle Company can complete the re -installation of the cook hood and
reinstall the fire prevention system.
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 fills
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.
Awvi Ase
Laurie Miller, R/W NAC, R/W-URAC
cc:
Attachments
City of Round Rock
ROUND
R°"4
TEXAS Agenda Item Summary
Agenda Number:
Title: Consider approval and execution of claim forms authorizing partial payment
of a moving expense in the amount of $3,666 for the Taqueria Chapala 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: 8/10/2018
Dept Director: Gary Hudder
Cost: $3,666-00
Indexes: RR Transportation and Economic Development Corporation (Type B)
Attachments: 00406938,PDF, 00406963.PDF
Department: Transportation Department
Text of Legislative File CM -2018-1811
Consider approval and execution of claim forms authorizing partial payment of a moving
expense in the amount of $3,666 for the Taqueria Chapala due to displacement of the
business caused by acquisition of right of way on the RM 620 project (Parcel 25).
This is a request for direct partial payment to Vendor for actual moving expenses. This
request for partial payment is due to the fact that the vendor has only completed part of the
job that was estimated and approved. Once the Taqueria Chapala has received their final
permits and the utilities are activated at the replacement business site the vendor will
complete the re -installation of the improvements. This payment is 100% reimbursable by
TxDoT in connection with the RM620 project.
Cost: $3,666. 00
Source of Funds: RR Transportation and Economic Development Corporation
City o/ Round Rack Page i Printed on 8/9/2018