CM-10-04-098CLAIM FOR ACTUAL MOVING EXPENSES
Print or Type All Information
-
1. Name of Claimant(s)
Austin Group for the Elderly
Parcel No:
County: Williamson
ROW CSJ No.:
Project No.:
❑ Residence /1
Business ❑ Farm .1 Nonprofit ❑ Sign 0 Other
2. Address of Property Acquired by State:
110 S. Brown St., Round Rock, TX 78664
Claimant's Telephone No.:
3. Address Moved To:
475 Round Rock West Dr., Ste 120, Round Rock, TX 78681
4. Occupancy of Property Acquired
From (Date):
1992
by State:
I To (Date of Move):
February 20, 2010
5. Distance Moved: 1.5 Miles
7. Mover's Name and Address:
❑ Owner/Occupant .1
Tenant
6. Controlling Dates
Mo.
Day
Yr.
a. First Offer in Negotiation
10
27
2009
9. Amount of Claim:
a. Moving Expenses
b. Reestablishment Expenses
c. Searching Expenses
d. Tangible Property Loss
e. Storage
f. Temporary Lodging
$
$
$2,500.00
$
$
$
b. Date Property Acquired
11
01
2009
c. Date Required to Move
03
20
2010
8. Property Storage (attach explanation)
From (Date): To (Date of Move):
Place Stored (Name and Address):
N/A
10. Temporary Lodging (attach explanation)
From (Date): To (Date of Move):
g. Total Amount
$2,500.00
1 1. All amounts shown in Block 9 were necessary and reasonable and are supported by attached receipts. Pay of this
not submitted any other claim for, or received reimbursement for, an item of expense in this claim, and that I will not
compensation from any other source for any item of expense paid pursuant to this claim. 1 further certify that all property
address shown in Block 3, above, in accordance with the invoices submitted and agreed terms of the move and that
included herein is true and correct.
4 R/e.4,t. 00 57/CI
claim is requested. 1 certify that I have
accept reimbursement or
was moved and installed at the
all information submitted herewith or
Claimant
Claimant
Date of Claim:
Spaces Below to be Completed by State '`' ,; , �:�}
1 certify that 1 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 of $ „______________,_..,,\.,..__________:,,,r.i........
gi, C),„ to
Date ` 0 2 i 1 i) F" , 4ilt i M(i) Valli-
SID -OAF-0%
AirD.Tzr.
of Transportation
Form 132
(Rev. 9/90)
(Electronic version GSD -EPC Word 97)
Page 1 of 1
BILLING INSTRUCTIONS: To facilitate handling and prompt payment show the information in the spaces provided below. Submit three
copies. Charges for freight or express, if any, must be supported by the prepaid freight or express bill. This statement cannot be
processed for payment without a valid payee ID number.
BILLING STATEMENT
Name of Payee: Austin Group For the Elderly
Address: 475 Round Rock West Dr., Ste. 120
DELIVERY DATE: April 19, 2010
Date: April 19, 2010
City & State: Round Rock, TX 78681
PAYEE ID NUMBER: 74-2431028
usetr.-ek9smagar
S
INVOICE
SOURCE
LINK
W
DATE
NUMBER
FY
S
UNIT
DESCRIPTION
QUANTITY
UNIT PRICE
AMOUNT
4/19/10
10
Austin Group For The Elderly
Relocation - Searching Expenses
Intermodal Transit & Parking Facility
City of Round Rock
1
$2,500.00
$2,500.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
CASH DISCOUNT % DAYS
TOTAL
$2,500.00
IAC or MISC SDHPT PURCHASE
CONTRACT NO.: REQ. NO.: 601 ORDER NO.: DATE:
CARD CODE 3 INFORMATION
LINK
SEQ
DIST
OR
DIV
SEG
ID
26
DETAIL
AMOUNT
±
DHT ITEM NO I
I
S EQUIPMENT
NUMBER
TRADE-IN
ALLOWANCE
TRADED
EQUIP NO
M
0
D
MMIS Tracked
Functions Only
09
10
DETAIL
AMOUNT
±
DHT ITEM NO
MOD.
STGY
EQUIP NO I
COST CENTER
SFI
70
THRU
79
DETAIL
AMOUNT
±
OBJ
EQUIP NO
F I
STGY
w
OF
I HIGHWAY
REF.
MARKER
AMT. OF
WORK
R
FUNC
EXP
TASK/
WORK
ORDER
CO
SYS
NUMBER
S
U
F
CL
PERF.
K
U
N
I
15 16 17
18 1920
21 22
23 24
25 - 41
42 - 53
54
55 56 57 58 59 60 61 62 63 64 65 86 87 68 69 70 71 72 73 74 75 76 77 78
BEG
END
T
Agency Verificat. n/Audit has been performed, the services rendered and/or goods received, and the invoice(s) correctly corresponds
under which proc meat was m ice(s) is (are) true and unpaid.
By ill Date 4430-10
with the authority
usetr.-ek9smagar
CLAIM FOR ACTUAL MOVING EXPENSES
Print or Type All Information kms;
1. Name of Claimant(s)
Austin Group for the Elderly
Parcel No:
County: Williamson
ROW CSJ No.:
Project No.:
❑ Residence
Business ❑ Farm "1 Nonprofit ❑ Sign ❑ Other
2. Address of Property Acquired by State:
110 S. Brown St., Round Rock, TX 78664
Claimant's Telephone No.:
3. Address Moved To:
475 Round Rock West Dr., Ste 120, Round Rock, TX 78681
4. Occupancy of Property Acquired
From (Date):
1992
by State:
1 To (Date of Move):
February 20, 2010
5. Distance Moved: 1.5 Miles
7. Mover's Name and Address:
❑ Owner/Occupant ® Tenant
6. Controlling Dates
Mo.
Day
Yr.
a. First Offer in Negotiation
10
27
2009
9. Amount of Claim:
a. Moving Expenses
b. Reestablishment Expenses
c. Searching Expenses
d. Tangible Property Loss
e. Storage
f. Temporary Lodging
$9,292.21
$
$
$
$
$
b. Date Property Acquired
11
01
2009
c. Date Required to Move
03
20
2010
8. Property Storage (attach explanation)
From (Date): To (Date of Move):
Place Stored (Name and Address):
N/A
10. Temporary Lodging (attach explanation)
From (Date): To (Date of Move):
g. Total Amount
$9,292.21
1 1. All amounts shown in Block 9 were necessary and reasonable and are supported by attached receipts. Pay of this
not submitted any other claim for, or received reimbursement for, an item of expense in this claim, and that I will not
compensation from any other source for any item of expense paid pursuant to this claim. I further certify that all property
address shown in Block 3, above, in accordance with the invoices submitted and agreed terms of the move and that
included herein is true and correct.
a aee.e_el 045/(C
/
claim is requested. I certify that I have
accept reimbursement or
was moved and installed at the
all information submitted herewith or
Claimant
Claimant
Date of Claim:
Spaces Below to be Completed 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. All items are considered to be necessary reasonable expenses and this claim is recommended for payment as follows:
Amount of $
/.& W, q 0
Date 1A0.1fe_ D k ti., r-, r- _"►,.1..tNii;i.tinsr-
..G. ll U,� 11 tti.
cm-
'TamsTa
ofTat/two htlon
Form 132
(Rev. 9/90)
(Electronic version GSD -EPC Word 97)
Page 1 of 1
BILLING STATEMENT
BILLING INSTRUCTIONS: To facilitate handling and prompt payment show the information in the spaces provided below. Submit three
copies. Charges for freight or express, if any, must be supported by the prepaid freight or express bill. This statement cannot be
processed for payment without a valid payee ID number.
Name of Payee: Austin Group For the Elderly
Address: 475 Round Rock West Dr., Ste. 120
DELIVERY DATE: April 19, 2010
Date: April 19, 2010
City & State: Round Rock, TX 78681
PAYEE ID NUMBER: 74-2431028
Ja�� R.Nuse,m .
MavtalQ-.
S
INVOICE
SOURCE
LINK
W
DATE
NUMBER
FY
S
UNIT
DESCRIPTION
QUANTITY
UNIT PRICE
AMOUNT
4/19/10
10
Austin Group For The Elderly
Relocation - Moving Expenses
Intermodal Transit & Parking Facility
City of Round Rock
1
$9,292.21
$9,292.21
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
CASH DISCOUNT % DAYS
TOTAL
$9,292.21
IAC or MISC SDHPT PURCHASE
CONTRACT NO.: REQ. NO.: 601 ORDER NO.: DATE:
CARD CODE 3 INFORMATION
±
DHT ITEM NO
9
DIST
SEG
ID
26
DETAIL
AMOUNT
I
S EQUIPMENT
NUMBER
TRADE-IN
ALLOWANCE
TRADED
EQUIP NO
M
O
D
MMIS Tracked
Functions Only
LINK
SEQ
OR
09
±
DHT ITEM NO I
DIV
10
DETAIL
AMOUNT
MOD.
STGY
EQUIP NO
±
COST CENTER
SFI
OBJ
EQUIP NO I
I
STGY
W
70
OF
I HIGHWAY
REF.
MARKER
AMT. OF
WORK
R
THRU
79
DETAIL
AMOUNT
FUNC
•.
EXP
TASK/
WORK
ORDER
CO
SYS
NUMBER
S
U
F
CL
PERF.
K
U
N
15 16 17
161920
21 22
23 24
25 - 41
42 - 53
54
55 56 57 58 59 60 61 62 63 64 85 66 67 88 69 70 71 72 73 74 75 76 77 78
BEG
END
T
Agency Verification/Audit has been performed, the services rendered and/or goods received, and the invoice(s) correctly corresponds with the authority
under which p rementwas made. T invoice(s) is (are) true and unpaid.
•
By Date 4 -3o -lo
_ _
Ja�� R.Nuse,m .
MavtalQ-.
CLAIM FOR ACTUAL MOVING EXPENSES
Print or Type All Information , -.,
1. Name of Claimant(s)
Austin Group for the Elderly
Parcel No:
County: Williamson
ROW CSJ No.:
Project No.:
❑ Residence ►1
Business ❑ Farm ►1 Nonprofit ❑ Sign ❑ Other
2. Address of Property Acquired by State:
110 S. Brown St., Round Rock, TX 78664
Claimant's Telephone No.:
3. Address Moved To:
475 Round Rock West Dr., Ste 120, Round Rock, TX 78681
4. Occupancy of Property Acquired
From (Date):
1992
by State:
1 To (Date of Move):
February 20, 2010
5. Distance Moved: 1.5 Miles
7. Mover's Name and Address:
❑ Owner/Occupant I
Tenant
6. Controlling Dates
Mo.
Day
Yr.
a. First Offer in Negotiation
10
27
2009
9. Amount of Claim:
a. Moving Expenses
b. Reestablishment Expenses
c. Searching Expenses
d. Tangible Property Loss
e. Storage
f. Temporary Lodging
$
$8,072.67
$
$
$
$
b. Date Property Acquired
11
01
2009
c. Date Required to Move
03
20
2010
8. Property Storage (attach explanation)
From (Date): To (Date of Move):
Place Stored (Name and Address):
N/A
10. Temporary Lodging (attach explanation)
From (Date): To (Date of Move):
g. Total Amount
$8,072.67
11. All amounts shown in Block 9 were necessary and reasonable and are supported by attached receipts. Pay of this
not submitted any other claim for, or received reimbursement for, an item of expense in this claim, and that I will not
compensation from any other source for any item of expense paid pursuant to this claim. I further certify that all property
address shown in Block 3, above, in accordance with the invoices submitted and agreed terms of the move and that
included her in is true and correct.
4 i U(7//,>-7/0
claim is requested. I certify that I have
accept reimbursement or
was moved and installed at the
all information submitted herewith or
Claimant
Claimant
Date of Claim:
Spaces Below to be Completed by State
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:
e
Amount of $
4io0. 30 �r
Date 1 /1 14 4 ,n r 0 t 1:tin-.1— ,) "r _ . Ae r'@ A. • -,1,41n
a.,i1 a-`- i-"
Ar
d Transpafatlon
Form 132
(Rev. 9/90)
(Electronic version GSD -EPC Word 97)
Page 1 of 1
BILLING STATEMENT
BILLING INSTRUCTIONS: To facilitate handling and prompt payment show the information in the spaces provided below. Submit three
copies. Charges for freight or express, if any, must be supported by the prepaid freight or express bill. This statement cannot be
processed for payment without a valid payee ID number.
Name of Payee: Austin Group For the Elderly
Address: 475 Round Rock West Dr., Ste. 120
DELIVERY DATE: April 19, 2010
Date: April 19, 2010
City & State: Round Rock, TX 78681
PAYEE ID NUMBER: 74-2431028
, J
NIuse P.C.-(54pakteice_
S
INVOICE
SOURCE
LINK
W
DATE
NUMBER
FY
S
UNIT
DESCRIPTION
QUANTITY
UNIT PRICE
AMOUNT
4/19/10
10
Austin Group For The Elderly
Relocation - Reestablishment Expenses
Intermodal Transit & Parking Facility
City of Round Rock
1
8,072.67
$8,072.67
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
CASH DISCOUNT % DAYS
TOTAL
$8,072.67
IAC or MISC SDHPT PURCHASE
CONTRACT NO.: REQ. NO.: 601 ORDER NO.: DATE:
CARD CODE 3 INFORMATION
±
DHT ITEM NO
DIST
SEG
ID
26
DETAIL
AMOUNT
I
S EQUIPMENT
NUMBER
TRADE-IN
ALLOWANCE
TRADED
EQUIP NO
M
0
D
MMIS Tracked
Functions Only
LINK
SEQ
OR
09
±
DHT ITEM NO
DIV
10
DETAIL
AMOUNT
MOD.
STGY
EQUIP NO I
±
COST CENTER'
SFI
OBJ
EQUIP NO
FSTGY
W
70
OF
I HIGHWAY
REF.
MARKER
AMT. OF
WORK
R
THRU
79
DETAIL
AMOUNT
FUNC
EXP
TASK/
WORK
ORDER
CO
SYS
NUMBER
S
U
F
CL
PERF.
K
U
N
I
15 16 17
18 1920
21 22
23 24
25 - 41
42 - 53
54
55 56 57 58 59 80 61 62 63 64 65 66 87 68 69 70 71 72 73 74 75 76 77 78
BEG
END
T
Agency Verification/Audit has been performed, the services rendered and/or goods received, and the invoice(s) correctly corresponds with the authority
under which procu ment vias -made- 1Tlvoice(s) is (are) true and unpaid.
By Date 4.;:30.1C)
, J
NIuse P.C.-(54pakteice_
AGE---Elderhaven ADC of Williamson County
Relocation Expenses
Work done Total Invoice EHWC Totals:
- ._.
IFI
Oving ! __.._......-
I
--
Move tables,etc.from Austin to new site i
------_
Earthy,Pricill#. ;A-Program Director cards I 43.3
McCarthy Print .
l - - --
. yr�Orrec#orcards �..� , ...____.._ -- ..._---
40.O,s u refoot deck. er Life;/Saf� Code Code:'TX De t Aging&`DisWli Adult I�~
q p ty ptY, 1-_ ----- --
__ �—
4 Outdoor,fenced,secure;covered space fl3�y Gare&,.Day Act Mealfih Services
6000
#reznents--subchapter C,98.42 Safety-
OM Electronic Engineering ;<gate I i ,
`ur5e�
Itiris' et0'4'4MARTIN
axwa e # }
11 52 111111 ON 11, 4i�ill
d
WMI I
MM
M MOM
M11101 MORT
all3
a
... ..
.._ w. ..... .._ -- - -. . ....
- y
r
ROUND ROCK, TEXAS
PURPOSE. PASSION. PROSPERITY.
Item Caption:
Approval Date:
City Manager Approval Summary Sheet
Consider executing 3 claims for actual moving expenses and 3 billing statements for
relocation assistance services in conjunction with the acquisition of land located at 110 S.
Brown for the Intermodal Transit and Parking Facility Project.
April 30, 2010
Department: Legal
Project Manager: Don Childs/Steve Sheets
Item Summary:
The tenant of the property 110 S. Brown had its business operations displaced as a result of this
acquisition. The Uniform Relocation Assistance Act requires that certain actual moving and other
reestablishment expenses be paid to displacees in these circumstances. The requested items are qualified
expenses under the Act.
Strategic Plan Relevance:
Mobility and Connectivity Strategic Initiative 2060 Vision: Residents and visitors
will have alternative choices for transportation including public transportation
options, pedestrian/biking options and personal vehicle.
Cost: $19,864.88
Source of Funds: 2002 General Obligation Bonds
REV. 3/8/10
00190721. DOC
05/12/2009
Request for City Council/City Manager Action
101 City Council 1:71 City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Legal
Contact Person: Don Childs / Lisa Dworaczyk / Rose McMillin ContractorNendor: Crossland Acquisition, Inc.
Project Mgr/Resource:
For Ad il4ist a oh' 1 LY
Ar'R 28 2010
Tag #:
Rece-o —t
eivt
Original Documents Received:
Project Name: Intermodal Transit and Parking Facility
Project Coordinator:
Assigned Attorney: Don Childs/Steve Sheets
City Council or City Manager Approval Date:
Agenda Wording
Funding Source: 2002 General Obligation Bonds
Additional funding Source:
Amount:
Account Number:
30 -Apr -10
$19,864.88
Consider executing 3 claims for actual moving expenses and 3 billing statements for relocation assistance services in conjunction with the acquisition of two parcels of land located at 110 S. Brown for the Intermodal Transit and Parking
Facility Project.
Finance Information
Is Funding Required? Yes io] No
Initial Construction Contract
Construction Contract Amendment
Change Order
Change in Quantity
Initial Professional Services Agreement
Supplemental Professional Service Agreement
Purchasing/Service Agreement
Purchase Order
Item(s) to be purchased
11jUnforeseen Circumstances
Other (Please clearly identify action on lines below)
Claims and Billing Statements for Relocation Assistance
Amount
$19,864.88
interest
Required for Submission of ALL City Council and City Manager Items
Project Mgr. Signature: Do Childs
Dept. Director Signature:
*City Attorney Signature:
City Manager Signature:
Date:
Date:
Date:
04/26/2010
4 —3o—t0
REVISED 04/28/2010
Settings \Idworaczyk\Latte: gca�jTt�Jar`
l Serr I/t3 Files\OLK64F\04-30-10_Don_Legal_RFA - Relocation Claims (00190723).XLS
BD
*City Attorney signature is required for all items.
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: Legal
Project Mgr/Resource: Don Childs/Steve Sheets
ECouncil Action:
ORDINANCE
Agenda Wording
Project Name: Intermodal Transit and Parking Facility
ContractorNendor: Crossland Acquisition, Inc.
I -I RESOLUTION
City Manager Approval
CMA Wording
Consider executing 3 claims for actual moving expenses and 3 billing statements for relocation assistance services in conjunction
with the acquisition of land located at 110 S. Brown for the Intermodal Transit and Parking Facility Project.
Attorney Approval
0/Attorney
Notes/Comments
Date
O:\wdox\SCCInts\0199\7123-BROWN\MISC\00190724.XLS
Updated 6/3/08