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CM-2018-1906 - 10/15/2018DocuSlgn Envelope ID 70C36E8F-BB67-4D3E-BAB3-108A74704F8D Form ROW -R-99 (Rev. 07111) Page 1 of 1 CLAIM FOR ACTUAL MOVING EXPENSES Print or Type All information 1. Name ofClaimant(s) Parcel No: County. Williamson William Montrcuii ROW CSJ: 0683-01-092 ProjectNo.: El Residence ® Business Farm Non roFit Sign ❑Other 2. Address of Property Acquired by State: 3. Address Moved To: 901 Round Rock Ave., STE 102. Round Rock, TX 78681 1050 Meadow Drive 11306, Round Rock, TX 78681 Claimant's Telephone No.: 512-246-9080 4. occupancy orProperty Acquired by State: 5. Distance Moved: fess than 1 Mile From (Date): To (Date of Move): 1 7. Mover's Name and Address: 12/01/2006 11/3/2017 OwaedOccu t 0 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 S. Property Storage (attach explanation) From (Date): NIA To (Date of Move): NIA c. Searching Expenses d. Tangible Property Loss $ 518,711.01 Place Stored (Name and Address): NIA e. Storage r Temper Lodain¢ S S 10. Temporary Lodging (attach explanation) From ate : NIA To (Date of Move):N/A g. Total Amount 618,711.01 11. Ali amounts shorn in Block 9 were necessary and reasonable and are supported by attached receipts. Pay orthis claim is requested. i certify that 1 have nor submitted any other claim for, or received reimbursement for, an item of orpense in this claim, and that I will not accept reimbursement or compensation from any other source for any item ormpense paid pursuant to this claim. I rdnher eerdry that all property was moved and Installed at the address shown in Block 3, above, in accordance with the invoices submitted and agreed term of the trove and that all information submitted herewith or included herein is true and corset. Claimant D81e of Claim: `i`,f Claimant 5 aces Below to be Completed by State/City ofItounaRock 1 certify that I 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 of519.711.01 omusigned br. 10/2/2018 LGOM°�l Date 1EME1342a.. it of Way Mampr CM-2-0(Y-60� r�lJr•7 P N�rll Pv Pv.4-9ity Manager DocuSign Envelope Ip 7006E8F-BB674ME-BAB3 108A74704F8D TO: Sheets & Crossfield Attn: Lisa Dworaczyk FROM: Laurie Miller MEMORANDUM September 20, 2018 Texas Department of Transportation Austin District Attn.: Sharma Pasemann SUBJECT: Parcel — Dr. William Montreuil ROW CSJ — 0683-01-092 Project: RM 620 Request Payment — Substitute Personal Property Expenses It is requested that the attached submission for be handled on a normal basis. In support of this request, please find the following: {�) Payment Request in the amount (s) of $18,711.01 (�) Form ROW -R-99, Claim for Actual Moving Expenses Form ROW -R-96 — Relocation Advisory Assistance — Parcel Record (�} Certification of Eligibility (�} W-9 Form (�) AP -152 Form (�1) Various Emails about the Purchase and Paid Invoice. EXPENSE VERIFICATIONS (4) Comments: The attached packet is a Request for Reimbursement for Substitute Personal Property Expenses for Dr. William Montreuil. The expense is not considered excessive. Relocation advisory assistance was not provided before or during Dr. Montreuil's move and reestablishment so it was never evaluated what the cost effectiveness would be if remodeling the replacement site to accommodate the old machine vs. purchasing the refurbished unit. Dr. Montreuil did not receive any money for his old x-ray machine that was picked up by a company that disposes machines that contain radiation. The attached documents are the documents that are available pertaining to the disposal of the old machine and the purchase of the new refurbished machine. The paid invoice included purchase, delivery, set up and hauling off the old machine. 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) 413-4012. Laurie Miller, RIW-NAC, RIW-URAC DocuSign Envelope It). 70C38E8F-B8674D3E-BAl33 108A74704F8D �w rs AZ. Forth ROWR-CE (Rev.GW16) Pape 1 of 1 CERTIFICATION OF ELIGIBILITY ROW CS3: C)Ua-6-ol -o9a Parcel: Displacee: w //bm I►1mWcu; 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: laimant DocuSign Envelope ID: 70C36EBF-BB674D3E-BA83-10BA74704FBD A : Displacee Move Plan ",, Form ROW -R -MP (1711 1) Page I of I Displacee's Name: RDW CSJ: QG S3 -0/- 0 ga Parcel No: Displacement Address: 901 / 0.1n o/ 4--k /Gee, , lee E30 Square Footage:— �d� , ;V151/ 1rJ Rent Lease Amount: $ yd'00' Replacement Address:, Specie! moving equipment needed: n /BJO manw/e/uf',!/`•t-w N 349 ❑ Pallet Jack ❑ emne %ru• rs� �n /C TF 7XJ,, ❑ Forklift ❑ Other ❑ Flatbed Distance of move: �: Date move to begin: Time needed for move: yQ/a Storage requited: AV Special utilityrequirements for replacement site: Hazardous or Regulated materials to be moved: 4011 Alam.4in/ [fes J 0 J /tr Mala fit /! ' ata s Ri-st a Zoning considerations: Regulatory issues: Permits needed: Contractors needed: [Electrician ffPlumbar uipment Technician Security System Technician ❑Other Date of personal property inventory (attached): Date of merchandise for resale inventory (attached): Other special requirements (attach additional sheets ifneoessary): Displacee's Signature: til/ Dispiacee'sName (printed): DISplacee'sTiddPosition QZ7-,Yrrr Relocation Agent's Si " The Texas Depar"ent or Trensp[sWw maintains the lrthxrnatlon cdlected through thls kxm, WAh few exceptions, You are crated an request to be informed atxxt the kdbnrwdm that we cotter abort you, Under Sections 552021 and 552023 of the Govewnent Code, You also are antlsed to receive kdomvdk and review Un n Under Section 559 -GN of the Government Code. you are also endged to have us carted Inkmnation about you that Is hoxrect *RMP* DocuSign Envelope ID. 70C36E8F-BB67-4D3E SA133.108A74704F8D 1-\ RADIATION MACHINE TRANSFEWDISPOSAL FORM TEXAS DEPARTMENT OF STATE HEALTH RADIATION SAFETY LICENSING BRANCH SERVICES Mail Code 2835 P.O. Sm 149347 Austin. Texas 7871¢9347 Fain{51212834113647-676W 7 exL 2225 DO NOT use this form to terminate your regis6 anion Note: ff One machine is replaced with another machine, and the tota necl rxtrr*er Of �� d� not charge, It is not necessary to submit this form Keep aA nrstallabon and transfeNdtsposaf records onsite for in spedrort purposes. Registration Number. R 24071 Business Phone Number: 592 248.90180 Legai Name of Business: Dental Healtttl Center of Round Rock Business Address: 901 ROUND ROCK AVE STE 102 ROUND ROCK TX 78681 RADIATION MACHINE DATA Complete the following information tbreach machine which is no longer in use. 1. Machine: p Storednnoperable O Transferred/Sold © Disposed Date; -10131W7 Site Number: 01Sde address: 1909 West Baker Lane Machine Category; RL Transferred To: .— Address TranskWed0bposedtSkwed: 1 0 Replaced this machine in same eakgorr.0 No 0 Yes Tota! nwnberof mares. ^emainin$ after trarsfertdsporal: 2- Mar hire: 13 Storedlinoperable 13 Trans%rmMold p Disposed Date. - Site Number.. Site address: Machine Category Transferred 70: �— Address TransferredoisposedtStored: Replaced th's maddne in same c2Wgwyt© No © Yes Toth mnnberof aad>FrresreaminliV at r trarlsleitdsposaf: 3. Machine: p storedAnoperable © Transferredtsold D Disposed Date: Site Number: Site address Machine Category: Transferred To: - Address TransferredUmposediStored: Replaced this machine in same caiegory. p No o Yes Tata! Hamm r of Medtnes remaining efts trarksfer/disposal: SIGNATURE of the appiic44 or person defy authorized to act on behalf of the applicant: (&&R k: RSO, P-d*r4 RegIANWAgmt CC* coo Mt P&bw and Owner) I certify that the information on tiros form is true and correct. 1's )e4 RAM r4pjwftO!vNe� iZt1YiED SIGMAI DATE NC tLLH �miYtlld hadptlp�� RmhM: WAal6 Paw I m DocuSign Envelope ID 70C36EBF 1313674ME-BAB3 10BA74704FBD �•az RELOCATION ADVISORY ASSISTANCE - PARCEL RECORD Foran ROW -R•96 (Rev.921t2) Pogo I oft SN M men tJ8V bi= Address (Place of Displacement): qO I Q- Ard Pec Ir- Ata 410L 2c rr,, )2r•c=k. 7 ( 7801 Phnne No. ;A a vA- i'm, Site or Apt No, -ja LL+Valc ❑ Female Fee Interest Before Datc Signed: iL! , 6 Duration: Lease Amount S: Utilities included? ❑ Yes Owner [K Tenant or or i yp e i Parcel No: - - Project No.: 4 New Address: 1010 01reirrle.ur P`S'& At 306 'Cor'd 2,-,A-73, -75' 735 1 PhoneNo.:,r-, a1%..1?Bde Site or Apt. No. -&o Code: white ❑ Black ❑ Hispanic ❑ Asian or Pacific Islander ❑ American indian/AlaskanNative ❑Other Fee Interest After Relocation: ❑ Owner hdTenant Date Signed: Ho /C1 ru» 1{,4s Duration; t 5:8t7� Lease Amount S: f (DOt " o Utilities included? ❑ Yes Type of Activity: q bra flAr ontinued Last two years income: Year 1: S 672 y o ,,,. Year 2: S 6/ate o� Terminated 1 01A Total Number of Number of Number ofBathrooms: Number of Roams Livin S i g pace (5q. ft,): Roams in Subject: t� N Bedrooms- tl, q Occupied: y, h A Displacx Income: (.Occupation (Where & What): 3. Other sources of eligible income: 2. Gross Last 12 Months: S a. Welfare (Source & Amounts) - The information contained within this form is being collected to allow the Agency to provide the best possible advisoryservices and to help identify all possible relocation benefits the displacee(s) is/am eligible for. By signing below I certify, to the best of my knowledge, that all the foregoing information is current and accurate nd that no information has been withheld or omitted. Dispiacee Signature: Date, Displacee Name (printed): Title: Zb"Gp/G Reason displaces verification not included: I Dote move Relocation Agents' Signature: Date: Relocation Agents' Name (printed): The Texas Deparknent of Transportation maintains the in WNUon mtkaed through this farm, With raw wogptlori% you are entitled on request to be inkrnied about the interni um that we cow about you, Under Seetlorrs 552021 and 552023 of the Government Code, you also ale entitled to receive and review this Inlbr r hon. Under SecOm 559,aW of the Government Code, you are also entitled to have us correct infarmadon about you that is hwffaa *R96* DocuVgn Envelope ID: 70C36E8F-BB67-4D3E-BAB3-10BA74704FBD F=rRnw•R-96 (Rev 01112) Nage 2 of 2 Relocation Agent Usc Only (continued) Date of Occupancy; Date Required to Move: Actual Date of Move: Distance of Move: 12/01/06 1012017 1 10-21-17 thru I1-3-2417 0.5 Miles Date Notified of Availability of Relocation Payments and Assistance (Services): Date Displacee Offered Assistance in Locating Replacement Housing or Operating Facility: Name of Other Agencies Assisting in Relocation: NIA Date of 90 day notice: Method used to determine eligibility: Dale of 30 day notice: Date of initiation of negotiations: Method used to verify income: Translator needed?: ❑ Yes ® No Languageofdisplawc: English Date and Substance of Follow-up Contacts (Lase extra pages if necessary): 1/25118 - Received phone call from Dr- Montreuil, we set up an appointment for Friday, January 26, 2018 at 10:00 am. 1/20118 -1 met with Dr. Monlreuil at his new replacement office approx. a half a mile a way from his old office on RM 620. [explained the relocation program and benefits and gave Dr. Montreuil a Relocation Brochure. We went through all of the rclo 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 I 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, 2/3/2018 -Mel 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 I 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. 2/4/18 - Dr. Monlreuil exchanged a few text messages about some of the dates he had. I prepared the claim farm for searching and sent to Dr. Montreuil for his signature. 219/18 -1 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 aflcmoon. DocuSign Envelope ID, 70C36E8F. BB67-4D3E-BAB3-108A74704F8D DACEW INC DBA HEWrIT DENTAL INC 1909 W BRAKER LANE, BLDG E, STE 400 AUSTIN, TX 787584025 1512) 873-8847 PHONE {512) 491-7520 FAX EWITT DENTAL EQUIPMENT * SERVICE A SUPPLIES Invoice Date Invoice No. 9J12J2017 E22491 DUNS#ahleA i, i� n hip To Bill To: 0 fr�� F WILLIAM J MONTREUIL, DDS 901 ROUND ROCK AVE. SIE 102 ROUND ROCK, TX 78681 Dental Health Center Of Round Rack 901 ROUND ROCK AVE, STE 102 ROUND ROCK, TX 78681 WILLIAM J MONTREUIL, DDS Purchase Order No. Project/office Due Date 11 /282017 Serviced/Ordered Qty Description Price Amount 81102017 1 VATECH PAX PRIMO NL SIN 011-15I0; 1 year parts warranty; 2 year labor Shipping & handling 16,896.00 389.00 16,896.00 389.00 We accept MasterCard A Visa for downpatyments under $10,000.00! Subtotal 517,285.00 Payments/ Credits -51 &711.01 Sales Tax (8.25%) 51,426.01 Total S18.71101 Total Amount Due $0,00 DocuSign Envelope ID: 70C36E8F-BB67-4D3E-BAB3-lO8A74704FBD From: Bill Montreuil Sent: Thursday, September 6,2018 12:55 PM To: Laurie Miller Subject; Fw: RE: Good AM Also here is the original email from our dental vendor for a replacement unit of the same style... remember we bought a refurbished unit Hope these helpl ----- Forwarded Message From: Diana Day <�Ia�aLh �ikt .M> To: To: Bili Montreuil <ftlpntE@.tjjJ id s��lfahoot9.4!!]> Sent: Monday, April 2,2018,10-32:44 AM CDT Subject: RE: Good AM Good morningl A new comparable unit is about $27K - Let me know if there is anything else I can help you with - Diana From: Bill Montreuil <montmullddIQyahoo.corn> Sent: Monday, April 2, 2018 9:22 AM To: Diana Day <d�anaIMh I.pom> Subject: Good AM Good morning, I am working with the relocation services for some reimbursements for our move and an item that came up was our Pano unit. They are requesting on paperwork what a new comparable unit might be I reached out to Travis and he referred me Bach to Hewitt. I reake the Pax -Primo is longer produced,so if you can please give a ballpark number if we bought a new off the floor comparable unit. Thank you DocuSign Envelope ID: 70C36EBF-BB674D3E-BA83-108A747G4F8D O AP 152 "r IV4-0:rej TEXAS APPLICATION FOR PAYEE IDENTIFICATION NUMBER • Shaded areas forstate agency use only - See Irxstructfons on back Fu Comptroller's use onty I Is this a new account? 0 YES Map Code coo 0 NO Enter Mail Cade J { Agency number Complete Sections I - V Complete Sections I, II & V L �–� a. PAYEE IDENTIFICATION NUMBER (PIN) - Indicate the typo of number you are providing to be used for your PIN. Gi 1 - Federal Employers Identification (FEI) Number [] 2 - Social Security Number (SSN) Enter the number indicated 0 3 - Comptrollers assigned number 3. Are you currently reporting any Texas lax to the Comptroller's Office other than unemployment (e.g.. sales tax, Iranchise tax) 7 0 YES 66 NO If 'YES,' enter Texas Taxpayer Number _ _- AYES I t-UHMA ON Please print 0-r type 4. Name nl payee (+ KrMdaal to busirxxs to bs pals) I William J Montreuil DDS PA dba Dental Health Center of Round Rock 3. LLtiltrtp address where you wont to Mwgve paymonS 1050 Meadows Drive #306 Q (DptAxyl) 7 (Qprronar) [----i e. fapuonar) 9, cry S we ZIP Code Round Rock TX f 78681 zone Code �J 10, SIC Code Payee telephone' number I + J Security Type Code U (0. 1. 2) (Area rode acrd number) 512 / z46 i —9� 080 J 11. OWNERSHIP CODES - Check only one code by the appropriate ownership type that applies to you or your business. 1 - Individual Recipient (not owning a business) J - Joint Venture a E - State Employee It checked, 0 L - Limited Partnership If checked. enter the Texas enter employing agency number 0 S - Sate Ownership (Individual owning e-business If Jecked, Fite Number I enter the owners name and Social Security Number (SSN) T - Texas Corporation If checked, enter the Texas Owners name Charter Number SSN z P - Partnership It checked, enter two partners names 0 and Social Security Numbers (SSN. It a partner is a V corporation, use the corporation's Federal Employer's rw Identification (FEI) Number. Name Name SSNIFEI SSNIFEI Type of service provided 0 N - Other If checked, explain L— A - Professional Association If checked, enter the Texas Charter Number 1_ 20-5978006 J C - Professional Corporation It checked, enter the Texas Charier Number o - Out -of -Slate Corporation 0 G - Govemmentai Entity r7 U - Stale agency I University M F - Financial Institution 0 R - Foreign (out of U.S.A.) zI 12. Payment Assignment? 0 YES 0 NO Note, A ropy of the assignment agreement between payees must be attachad. Assignee name Assignee PIN 13. Comments sign 14, dere Agarm nome is, Assignment data City of Round Rock ROUND TCXOROCK Agenda Item Summary Agenda Number: Title: Consider approving a $18,711.01 claim for actual payment of moving expenses for the relocation of x-ray equipment at the dental office property due to displacement caused by the RM 620 project. Type: City Manager Item Governing Body: City Manager Approval Agenda Date: 10/12/2018 Dept Director: Gary Hudder Cost: $18,711.01 Indexes: RR Transportation and Economic Development Corporation (Type B) Attachments: 00411162.PDF, 00411161.PDF Department: Transportation Department Text of Legislative File CM -2018-1906 Consider approving a $18,711.01 claim for actual payment of moving expenses for the relocation of x-ray equipment at the dental office property due to displacement caused by 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 third expense claim to be submitted, the first was for $68,858.94 and the second was $2,500. This claim will be reimbursed by TXDOT in the amount of $15,069.95. Any future claims by this tenant will be reimbursed at 100% by TXDOT. Cosi: $18,711.01 Source of Funds: RR Transportation and Economic Development Corporation (Type B) Clly of Round Rock Page 1 Printed on IWIlaoi9