CM-2017-1305 - 1/27/2017Form ROW -R-100
(Rev U711 1)
Page 1 of 2
CLAIM FOR FIXED MOVING EXPENSE PAYMENT - INDIVIDUALS AND FAMILIES
1. Name ofClaimant(s):
Parcel No.: 18 1 County: Williamson
Bobby C. Owen, Jr.
ROW CSJ: 0683-01-092 1 Project No.:
A. Occupancy of Property Acquired by State
From (Date): November 2007
To (Date of Move): January 7,
2017
5. Controlling Dates Mo. Day Yr.
a. First Offer in Negotiations 9 9 2016
2. Address of Property Acquired by State:
b. Date Property Acquired 10 31 2016
1000 Glenwood Street
c. Date Required to Move 1 7 2017
Round Rock, Texas 78681
6. Dwelling:(house, apartment, etc.)
House
X Owner -occupied ❑ Fumished
❑Tenant X Unfurnished
A t. No.:
3. Address Moved To:
(i) Number of Rooms: 9
PO Box 2166
Trinity, Texas 75862
(2) Payment Schedule Amount $ 2,050
(3) Total Amount of Claim: $ 2,050
Apt. No.
7. Payment of this claim in the amount shown in Block 6 (3) is requested. I certify that I have not submitted any other claim
for, or received reimbursement or compensation for, any item of expense pursuant to this claim, certif that all
information shown above is true and correct.
�Ifttrther
Claimunt
Datc ol'Claim
Claimant
Spaces Below to be Com leted by Stale
8. Type occupancy and ntunber of rooms verified prior to
9. Vacancy verified on:
move on:
Date: Atust 25.2016
By: c.l`F31�---�
Date: J uary 9, 2017
By: ';e' ._--
Signature
si nutum
I certify that I have examined this claim and found it to conform to the applicable laws and regulations governing relocation
assistance payments. I further certify the computation of the payment and the information as shown herein is correct. This
claim is recommended for payment. This claim is recommended for payment as follows:
Amount of :$ 2,050
!� t
Date
Right of Wa Manager w
Laurie Hadley City Manager
-- * R 1 0 0
�`/v1, 2 C- ��� ��`�
-Form ROW -R-100
(Rev. 07/11)
Page 2 of 2
Breakdown of Room Count Claim
Print or Type All Information
Room Description
Number of Rooms
in Unit
Number of Rooms
in Claim
Living Room
1
1
Dining Room
1
Kitchen
1
1
Family Room
Bedroom
3
3
Study
Kitchen -Den
Living Room -Den
Den
Living Room -Dining Room
Sleeping Room
Others
Basement
Garage
1
1
Storage Room
1
1
Attic
Utility Room
1
1
Total
9
9
Remarks: (Where totals in the two columns differ by line item explain in "Remarks")
( _r
Signed
Ta+aa
/rpvm,om
IX Ruupabfbn
DISPLACEE CERTIFICATION OF COMPLETION OF THE RELOCATION PROCESS
ROW CSJ: 0683-01-092
County: Williamson
Highway: RM 620
Parcel: 18
Displacee(s): Bobby C. Owen, Jr.
Form ROW -R -DC
((36/12)
Pagel of 1
The undersigned displacee hereby certifies the following. The relocation process has been
completed. TxDOT's relocation assistance program was explained to the displacee. Throughout the
relocation process advisory services were provided by the relocation agent(s). Relocation assistance
payments which applied to this relocation were thoroughly described to the displacee and all
eligibility requirements were explained. At this time the displacee has received all reimbursements
and no additional claims will be submitted.
These documents were received by the displacee.
® Relocation Assistance Booklet
® Relocation Assistance Letter
Displacee - if the information above is not accurate do not sign this form. Contact the local TxDOT
office for assistance.
Displacee's Signature
Bobby C. Owen, Jr.
Displacee's Name (Printed)
Relocation Agent's Signature
Thomas L. Doss
Relocation Agent's Name (Printed)
o/ -- p 7 -- z o / 17)
Date
1- 1"7
Date
*RDC*
Form ROW -R -CE
(Rev. 03/16)
Page 1 of 1
CERTIFICATION OF ELIGIBILITY
ROW CSJ: 0683-01-092
Parcel: 18
Displacee: Bobby Owen, Jr.
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:
Claimant
City of Round Rock
ROUND ROCK
TEXAS Agenda Item Summary
Agenda Number:
Title: Consider approval of a claim for fixed moving expense payment on Parcel
18 (Owen).
Type: City Manager Item
Governing Body: City Manager Approval
Agenda Date: 1/27/2017
Dept Director: Steve Sheets
Cost: $2,050.00
Indexes: RR Transportation and Economic Development Corporation (Type B)
Attachments: 00371258.PDF, 00371255.PDF
Department: Legal Department
Text of Legislative File CM -2017-1305
Consider approval of a claim for fixed moving expense payment on Parcel 18 (Owen).
The City has purchased the residence on Parcel 18 and the landowner has chosen not
to purchase a replacement home. The Uniform Relocation act allows for actual moving
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.
Pursuant to the project funding agreement, this payment is 100% reimbursable by
TxDoT.
Cost: $2,050.
Source of Funds: RM 620 ROW
City of Round Rock Page 1 Printed on 112 612 01 7