CM-2019-0120 - 5/10/2019DocuSign Envelope ID: 602BF1A4-E768.4C2E-ACED-S5ME385802C9
Form ROW. ins
(Rev. 07111)
Pape 1 Oil
CLAIM FOR ACTUAL MOMG MENSES
' Prlittor Type
All rrtiratntaHoa
1. Nmne of Clalman! sy
ParcelNo: 25-02 County: W ililamsoa
Carlos Lopez
ROW CSI: 0661-01-092 Project No.: NIA
11 Residence Business D Farm
Naa mist 0 Sin 00ther
2. Address orproperty Acquired by State:
3. Address Moved To:
712 Round Rock Am
1308 Round Rock Ave.
Round Rock, TX 78681
[Lound Rock TX 78681
Claimant's Tel honeNo.:512-663-6674
4. occupancy of Property Acquired by State;
3. Distance Moved: l Miles
From (Data): To (Date of Move):
7. Movees Nun and Address:
2002 Au 3 2018
OWne nl MTMMI
6. Controlling Dates Mo. flay Yr.
n. First Offer in Negotiation 2 24 17
9. Amount or Claim:
a. Moving Expenses
b. Reestablishment Fa:penses
S
S 12,250.00
b. Date Property Acqulmd 6 30 I8
r Dote Rc uired to More 8 3 2016
8. Property Storage (attach explanation)
From (Date): NIA To (Date of Move): NIA
c. Searching Expenses
d. Tangible Property Loss
S
S
Piave Stored (Name and Address):
NIA
e. Storage
S
1 D. Temporary Lodging (attach explanation)
From ate:N/A To ate of Move -N/A
g. Total Amount
550.00
11 _ All amounts drown In Block 9 %ram necessary and reasonable and aro suppomd by attached nulpts. Pay of this claim is requestc& l ct&y that t fin.
oot submitted any oil= claim for, or tete relmbarsement far, un hem orc+rpsren
ease in this claim, and that l vnN not accept rdrabuisert or
compertatian from any Wier source tram of expense paid pursuant to this claim. I further cmi y that all property Was moved and installed at the
addnes:boson In Btotk 3, above, arca with dw Invoices submitted and agreed tents ardra move and that all (malleation subnrined hcr,04h or
Included herein is tma and cons
r
Claimant
Data orClaim: 4/4/19
Claimant
Spaces -Bal6w to be Completed by State
I =11HY that F Iran examined Orfs claim and subsientiatinR documentation attached lrerewM, nod have Ibund It to be Mo and Correct and to eonrorns with
the applicable provisions orSisto law. Ail items arc considered to be necessmyr reasonable expenses and Otis claim is recommended for payment as failmr.
Amountors 12,250.00
W.
Dmaignedr
4/26/2019
V"i4 6
Date
100) OK11 rt orway M
City of pund Rock Approved:
By: (Z I UZZZLLW Y Ld
,( ! Its: Y
C(ZO
DocuSign Envelope Id 602BF1A4 E7664=-ACED-556E385802C9
Parcel 25-02—Taqueria Chapala
RM 620
Rent Differential
Lease Amount for Acquired Property $4,677.00
Lease Amount at Replacement Property _ $5,312.60
Increase of Rent Per Month $635.60
Difference in tient x 24 months = $15,254.40
CSJ # 0681-01-092
Base Rent $3,400.00 + $1,277 - $4,677.00
i:'AM - $1,689.60+ Rcnt $3,623.00 $5,312.60
Mr. Lopez would like to claim the remaining balance of his re-establishment funds for this claim of rent
differential under an increase in operating cost. The replacement site is larger than the acquired site,
but Mr. Lopez wanted to stay as close as possible to the acquired property so that he would not lose his
customers and the replacement site was the only thing available in the immediate proximity to the
acquired property.
The acquired property lease and replacement lease are attached.
The remaining balance of the $25,000.00 Re-establishment funds are: $12,250.00
The square footage of the acquired property was 1,4I5 sq. ft. (In appraisal), Mr. Lopez says that he paid
rent for approx. 1800 sq. ft. The square footage of the replacement site 1900 sq.R.
DocuSign Envelope ID: 602BF1A4-E766AC2E-ACED-556E385802C9
Request for Relocation Payment
l7ep�arnnenr
nt Trarrsportatlon
ROW -R Payment Request
Rev. 1110212017
Highway Project
RM 620
Parcel No. 25-02
PMC Project Manager
Segment:
ROW CSJ: 0683-01-092
Limits From:
LH 69
CCSJ: NIA
Date:
To:
Harris County Line
Federal No.: NIA
Date:
Name:
Carlos Lopez — Taqueria Chapala 2
Amount of Payment Request: $12,250.00
Application for Texas
SS #: 454-94-8453
Identification Number
(AP -152)
FEIN #:
❑ Housing Supplement
❑ Actual Cost Self -Move
❑ Actual Cost Commercial Mover
❑ Rental Supplement
❑ Incidental Exp. to Transfer
® Room Count
❑ Residential Claim:
❑ Increased Interest
❑ Incidental Exp. for
❑ Temp. Storage and/or Lodging
❑ Down Pymt. Supplement
Replacing Housing
❑ Searching Expenses
® Reestablishment
❑ Negotiated Self -Move
® Non -Residential
Expenses
Claim:
❑ Temporary Storage
❑ Actual Cost Self -Move
❑ Fixed Moving Payment
❑ Actual Cost Commercial
❑ Actual Direct Loss of
❑ Purchase of Substitute Personal
Mover
Tangible Personal Property
Property
❑ Advance Payment for Residential or Non -Residential
❑ Direct Payment to Service Provider (Mover, Utility Company, etc.)
❑ Exception to Policy (if requested please explain why in the comments)
Parcel Controlling Dates
Occupancy of Property
10/6114
Offer Letter
2124117
90 Day Letter
417/17
Property Acquired
6130118
30 Day Letter
612118
Estimated Vacate Date
814118
Comments:
Aeoroval•
Signature:
Date -
Relocation Agent
414119
PMC Project Manager
TxDOT Project Manager
Payment Request Received:
Date:
Processed in ROWIS:
Date:
Warrant Received
Date:
Warrant Delivered to
DB Contractor
Date:
Payment Request Form - Relocation (Rev 09117) Page 1 of 1
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City of Round Rock
OU
ROCK
TEXAS Agenda Item Summary
TEXAS
Agenda Number:
Title: Consider approval and execution of claim forms authorizing reimbursement
of actual re-establishment expenses in the amount of $12,250 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: 5/10/2019
Dept Director: Gary Hudder
Cost: $12,250.00
Indexes: RR Transportation and Economic Development Corporation (Type B)
Attachments: t.AF and Claim.PDF, Claim Doc.PDF
Department: Transportation Department
Text of Legislative File CM -2019-0120
This is a request for reimbursement payment to a tenant for re-establishment expenses. This
request is for the balance of the re-establishment funds for this tenant to cover the increase in
operating cost. This payment is 100% reimbursable by TxDoT in connection with the RM620
project.
Cost: $12,250.00
Source of Funds: RR Transportation and Economic Development Corporation (Type B)
Ctty efRound Rock Page f Printed on &912019