CM-2019-0085 - 3/29/2019DocuSign Envelope ID F39489DF W544662 BB27 A281 A7622362
Form ROW -R-99
(Rev. 07111)
Pape 1 of 1
CLAIM FOR ACTUAL MOVING EXPENSES
F 1
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City Manag-r
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CP 5
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Print or Type All'Ibformation
I. Name of Claimant(s)
Parcel No: 25-02
County: Williamson
Carlos Lopez
ROW CSJ: 0681-01-092
Project No.: NIA
Residence 0 Business
❑ Farm LJ Nonprofit Si Other
2. Address of Property Acquired by State:
3. Address Moved To:
712 Round Rock Ave.
1308 Round Rock Ave.
Round Rack, TX 78681
Round Rock, TX 78681
Claimant's Telephone No.: 512-663-6674
4. Occupancy of Property Acquired by State:
5. Distance Moved: 1 Miles
From (Date): To (Date of Move):
1
7. Mover's Name and Address:
2002 August 3, 20I8
Negotiated Self Move
Owner/Occu t ® Tenant
6. Control ling Dates Mo. Day
Yr.
a. First Offer in Negotiation 2 24
17
9. Amount of Claim:
a. Moving lxpcnses
b. Reestablishment Expenses
S
S
b. Date Property Acquired 6 30
18
c. Date 8Suired to Move 8 3
2018
8. Property Storage (attach explanation)
From (Date): NIA To (Date of Move): N/A
c. Searching Expenses
d. Tangible Property Loss
S
s
Place Stored (Name and Address):
NIA
e. Storage
C Temporary Lodaing
$615.80
S
10. Temporary Lodging (attach explanation)
From (Date): NIA To ate of Move :NIA
g. Total Amount
S 615.80
11, All amounts shown in Block 9 were necessary and reasonable and aro 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 claire, and that I will not accept reimbursement or
compensation from any other source f r any item of expense paid pursuant to this claim. l fitAcr certify that all property was moved and installed at the
address shown in Block 3, ab r, ' x ,ccordance with the invoices submitted and agreed tams of the move and that all information submitted herewith or
included herein is true ant to °
Claimant
Date of Claim: 127119
Claimant
S
ces Below to ba:Com leW by State
I 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. Al( items are considered to be necessary reasonable expenses and this claim is recommended for payment as follows:
Amount orS 615.80
o""ma"id W.
3/18/2019
V"i� (}AWAL
Date
#DDOFfiEM13I2e.Ri t of Wgy Manager
F 1
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City Manag-r
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CP 5
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DocuSign Envelope ID: F39489DF-8D54-4662-BB27-A281A7622362
Foran ROW -R-103
(Rev. 07118)
Page 1 oft
REQUEST FOR AUTHORIZATION -
STORAGE OF PERSONAL PROPERTY AND/OR TEMPORARY LODGING
]Print ox
To:
TXDOT
City of hound Rock
1. Applicant's Name:
Carlos Lopez _
3. Address of Property Acquired by State:
712 Round Rock Avenue
Round Rock, TX 78681
S. Occupancy of Property Acquired by State:
From (Date): 2002 To (Date of Move): 7r1?JI 6
Ll Individual - Family ® Tenant
Q Owner -Occupant ❑ Farm Operation
- Read ]Rules on Reverse Side
Parccl No.: 25-02
ROW CSI: 0663-01-092
2. Applicant's Telephone No.:
3. Place of Storage or bodging (Name
: Williamson
No.: NIA
Telephonc No.:
6. Estimated Period of Temporary bodging:
From (Date): NIA To (Date of Move): NIA
7. Estimated Period of Storage:
From (Date): 7/23118 To (Date of Move): 10/30/18
busl Ll Nonprofit PrEEization
8. Authorization is requested for storage ofpersonal property and/or temporary lodging for the period shown in Blocks 6 and 7 above for
the reasons indicated in the attached statement. It is understood reasonable storage and/or tem : lodging cast can only be paid upon
presentation of receipted bills as a part of an actual cost move. l certify that i have read and and - nd the rules listed on the reverse side
of this application and that all information attached hereto or included herein is true and
W*pplicant's
By:
719118 Signature
Date ofRequest
that I have examined this request
and supporting
Ownep
Title or Position (Owner, Manager, Etc.)
❑ Recommend as reasonable and necessary temporary lodging fora palod not to exceed
® Reeommend as masonabTe and necessary storage for a period not to cccmd 3 months.
❑ Find that we cannot authorim storage of personal property and/or temporary lodging because
(List reasons payment cannot be authorized. Use extra page if necessary)
-71271 &
Date
Storage o€personal Property erty andlar temponuy lodg
Dale.� �.�
approved for a
By'
not to
.?aP trrvsdr
11, 1kjk1
DocuSign Envelope ID. F39489DF.8054-4662-BB27-A287A7622362
FROM: Life Storage #545
506 McNeil Rd
Round Rock, TX 78681
TC: Carlos Lopez
1616 War Horse Ln
Round Rock, TX 78664
DETAIL ON YOUR MOVE -IN PAYMENT
Rent
Admin
Merchandise
Ins
Sales Tax
Total Payment
Applied Credits
Total Transaction Customer Signature
RECEIPT #24479
7/23/2018 12:37:49 PM
Space 00112
$51.97
$25.00
$21.99
$12.90
$1.81
$113.67
$179.00
$292.67
Payment made by CREDIT CARD - MasterCard xxxx1081 - AUTH: 023730 Swiped.
Merchandise Purchased Qky price LU Total
LS-CL19TWIN Lock Double CAI 1 $21.99 $1.81 $23.80
Your next rent is due on Saturday, September 01, 2018. A late charge of $15.00 is imposed if
you are 5 days late.
There are no monies outstanding.
Charges for 9/1/2018 to 1011/2018
Rent $1.79.00
Ins $10.00
$189.00
THANK YOU VERY MUCH FOR THIS PAYMENT.
X
Cardholder agrees to pay above total amount according to card Issuer agreement
X J iggi <electronically signed>
Manager 0155-7939
Refund Policy on merchandise: original receipt required within 30 days of purchase. No partial refunds on bundled Items.
Page 1 of 1 Pay online at www.lifestarage.com Printed 7/23/2018 12:39:48 PM
DocuSign Envelope ID. F39489DF-8D544662 BB27 A28IA7622362
FROM: Life Storage #545
506 McNeil Rd
Round Rock, TX 78681
To; Carlos Lopez
1616 War Horse Ln
Round Rock, TX 78664
RECEIPT #25197
9/18/2018 10:12:34 AM
Space 00112
Before this transaction, your rent was due on Saturday, September 01, 2018.
DETAIL ON YOUR PAYMENT
Rent $179.00
Late $15.00
Ins $10.00
Total Payment $204.00
Payment made by CREDIT CARD - Visa xxxx7129 - AUTH: 036077 Swiped
Your next rent is due on Monday, October 01, 2018. A late charge of $15.00 is imposed if you
are 5 days late.
There are no monies outstanding.
Charges for 10/1/2018 to 11/1/2018
Rent $179.00
Ins $10.00
$189.00
THANK YOU VERY MUCH FOR THIS PAYMENT.
r
Cardholder agrees to pay above total amount according to card issuer agreement
X ]ohWicginsIII <electro igned>
Page 1 of 1 Pay online at www.lifestorage,com Printed 9/18/2018 10:12:49 AM
DocuSign Envelope ID. F39489DF-8D54-4662-BB27 A281A7622362
Storage break down — RM 620 — Parcel 25-02 — Taqueria Chapala #2
7/23/18 —8/31/18 — Rent $179.00
Admin $25.00
Insurance $10.00
Total $214.00
9/1/18— 9/30/18
Rent $179.00
Insurance $10.00
$189.00
10/1/18-11/1/2018 Rent $179.00
Insurance $10.00
Total $189.00
lock +Tax $23.80
Grand Total $615.80
Claim 615.80
DocuSign Envelope 1D F39489DF 8D54-4662 8627-A281A762236P
MEMORANDUM
March 13, 2019
TO: Sheets & Crossfield
Attn: Lisa Dworaczyk
FROM: Laurie Miller
SUBJECT: Parcel 25-02 — Taqueria Chapala 2
ROW CSJ — 0683-01-092
Project: RM 620
Texas Department of Transportation
Austin District
Attn.: Shanna Pasemann
Claim — Moving Expenses -- Request Reimbursement for payment of S615.80 for Approved Personal
Property Storage at Life Storage.
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 5 615.80
(4) Form ROW -R-99, Claim for Reimbursement of Moving Expenses
(4) Certification of Eligibility
(J) ROW -R-96
(4) W-9 and AP -152
EXPENSE VERIFICATIONS
(�) Comments: The attached packet is a Request for Reimbursement of Storage Fees (Moving
Expenses)
This packet is a request for reimbursement for 3 months of storage — Pre -Approved
There will be additional claims to come in the near future.
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.
I 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, R/W-URAC
Attachments
JOUN1RP"—
City of Round Rock
CK
R° Agenda Item Summary
Agenda Number:
Title: Consider approval and execution of claim forms authorizing reimbursement
of actual re-establishment expenses in the amount of $615.80 for the
Taqueria Chapala due to 3 months of temporary storage 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: 3/29/2019
Dept Director: Gary Hudder
Cost: $615.80
Indexes:
Attachments: LAF.PDF, Claim for Actual Moving Expenses.pdf
Department: Transportation Department
Text of Legislative f=ile CM -2019-0085
This is a request for reimbursement payment to a tenant for re-establishment expenses. This
payment is 100% reimbursable by TxDoT in connection with the RM620 project.
Cost. $615.80
Source of Funds: RR Transportation and Economic Development Corporation
Clty of Round Rock Page Y Pdn(ed on 3129P1019