CM-2024-172 - 6/21/2024DoctSlgn Envelope ID DCCA84F3-050C-45[)D-816D•5E440CB5534A
Ppp4 10111
CLAIM FOR ACTUAL MOVING EXPENSES
Print *rTyft
Alt Sefnimis! a
1. Name of Claimant(s)
Parcel No: Burge Parcel
County: Williamson
Landon Burge
Project: Old Settlers Blvd
Residence Business Farm
Non raft Sin
El Other
2. Address of Property Acquired by City of Round Rock:
3. Address Moved To:
1001 N. Redbud Lane
Remainder
Round Rock, Texas 79664
Claimant's Telc hone No.:
4.Occupancy of Property Acquired by Cit) of Round Rock:
5. Distance Moved: Remainder
From (Date): To (Date of Move)-.
7, Mover's Name and Address:
1992 1 5-31-2024
Quality Mobile Nome Service and Construction LLC
452 Pebblestone Road
Dale, Texas 79616
Cq Owner/Occupant
Tenant
6. Controlling Dates
Mo
Day
Yr.
512-718-7247
a. First Offer in Negotiation
02
08
2023
9. Amount of Claim:
Moving Expenses
S4,800.00
b. Date Property Acquired
2024
e. Date Required to Move
04
14
2024
8. Property Storage (attach explanation)
From (Date): N/A To (Date of Move): NIA
Place Stared (Name and Address):
NIA
Total Amount
S4,800.00
10. Temporary Lodging (attach explanation)
From (Date): NIA To Date of Move : MA
I I All amounts shown in Block 9 were necessary and reasonable and arc supported by attached receipts Payment of this claim is requested I certify that 1
have not submitted any other claim for, or received reimbursement for, an item of expense en this claim, and that 1 will not accept reimbursement or
compensation from any other Source For any item ofexpense paid pursuant to this claim I further certify that all property was moved and installed at the
address shown in Black 3, obov %%%11h the invoices submitted and agreed terms of the move and that all information submitted herewith or
included herein is true and c
Date of Claim 6/6/2024 rmant
Claimant
S nor BeY,terr to be Cociphbd bry Cft or R& nd
1 Certify that I have examined this claim and subslant.ating documentation attached hcmwith p4,havc found it to be true and correct d to conform with
the applicable provisions of State law All items are cons!dered to be necessary rcmrtnb! prns and th clatm is ommendod payment as follows
Amount of f 4,800 00
47
Datelexat
Agent
0�2tA?��
Date
City of RoundCity of Round Ro :k�ve
C,4- / -7 O
DocuSign Envelope ID, DCCA84F3D5DC-45DO-816D-5E44DCB5534A
CITY OF ROUND ROCK, TEXAS
ACCOUNTS PAYABLE
221 East Main Street, Round Rack, Texas 78664
Pursuant to internal Revenue Service Regulations, we ask that you furn;.sh the
City of Round Rock with your Taxpayer Identification Number (TIN). If this
number is not provided, IRS regulations require us to subject you to a 20%
withholding on each payment. To avoid this withholding and to ensure that
accurate tax information is reported to the Internal Revenue Service, we would
appreciate your cooperation in providing us with the information requested
below.
Please contact the City of Round Rock Accounts Payable Division at (Sl?) 218-
5434 if you have any questions or problems with this request.
Thank you for your assistance in this matter.
BUSINESS ENTITY:_ (please check only one)
X Individual Partnership Sole Proprietorship
__Estate/Trust Corporation Public Service Corporation
Governmental/Non-profit Other:
Individual:, list name as shown on your social security card and
your social security number.
Sole Proprietorship: list owner's legal name followed by the legal
business name and list the owner's social security number.
All others:_ list the legal name of your corporation, partnership,
organization, or other legal entity and list your Employer
Identification Number.
LEGAL BUSINESS NAME:Landon Burge_
ADDRESS
1001 N Red Bud Ln
Round Rock, Tx 78665
9 nTGTT TAXPAYER TDF.NTIFTCATTON iTTNI:
Social Security Number:
Federal Employer Identification Number:
_sc=mvecccaaanvcveeaeexeaaec=eavmm�zaasaa a.^.�ssa:as:aasaaacaco=oc3a=Qaaaaara�nn=
UNDER PENALTIES OF PERJURY, AND TO THE HEST OF MY KNOhILEDGE AND BELIEF, I
DECLARE THAT THIS FORM HAS BEEN COMPLETED FULLY AND ACCURATELY.
Landon Burge y
Name &g$y .Type) Titre (Print or Type)
6/6/2024
Signa
Date Telephone Number
ASSIGNED VENDOR: ASSIGNED BY:
Revised 01/14/04 W-9 FORM
Quality mobile home service and construction ilc INVOICE
INVO359
Business Number 512-7187247
452 Pebblestone rd dale tx DATE
betancourtmhservice@gmail.com May 30, 2024
DUE DATE
Jun 1, 2024
BALANCE DUE
use $0.00
BILL TO
Landon burge
DESCRIPTION RATE OTY AMOUNT
1001 N Red Bud Ln, Round Rock, TX 78666 $4,000.00 1 $4,000.00
Breakdown 28x52 dw and move up property
House cat $800.00 1 $800.00
SUBTOTAL $4,800.00
TAX (0%) $0.00
TOTAL $4,800.00
PAID-$4,800.00
.fun 3, 2024
BALANCE DUE U$D $0.00
l InUoi� �
10; 27 S L! s AO - 4 +s o sc uc A 94%9
E- (512) 718-7247 E31 %
Wednesday, Apr 3.1:50 PM
1001 N Red Bud Ln, Round Rock
T
860
Not 100% sure on Final location yet, but
the approximate address is estimated
somewhere around this one.
16035 Romberg Rd Holland TX 76534
Also, can you break it down into cost to
prep for the move, then the actual
hauling?
It's a 1"S. no axles or tongues.
Thank you
Break down deliver and install 6500
New tongues 1000
House cat if needed for sandy or tight
parking 600
Our land is being taken by the city and
we don't have a replacement piece yet.
That's why all the strange questions. Up
against a timeline to move it and
nowhere to put it yet
I understand
Break down deliver no set 4800
Thursday, Apr 4.10.28 AM
Let me know if we need to adjust things
or if your on a budget we can help
Q Text message 9 Q+ 4'
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Old Settlers
Burge Parcel
Mobile Home Displacement Pictures
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Old Settlers Blvd
Burge Parcel
MH Move Pictures on Remainder 5-27-2024