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/ ROW
Residential Relocation Checklist
Instructions for Use:This form should be completedby the ROW Chief Negotiator/Relocation Supervisor after relocation studies have been submitted by the LPA.
Local Public Agency (LPA): / LPA Responsible Charge:
State Project No.: / Project Name and Location:
State Control No.: / Date of Review: / Form Completed By (Print Name):
Name: / Tract:

Address:

Old Address:

Old Phone: / Home Phone: / Business Phone:
Occupancy Status: Owner Partial Owner Occupant Tenant
Occupancy length: 180 day 90-180 day less than 90 day
Initial Interview Call Report / Y / N / NA / Residential Study Package / Y / N / NA
Item / Item
Date & time noted / Cover sheet DR Form 285
Brochure given / Service information DR Form 49, Incl. Cert. Legal Res.
Right of appeal discussed / Subject property DR Form 54
Advisory services offered / DR Form 54 - determination of # of rooms for scheduleamt.
Who accepted/denied advisory services / Photo of subject
Tax liability Advice / Grid comparison DR Form 59
Explanation of benefits / Comparables DR Form 53
Completed forms DR Form 49, 54, or 76 / Computation DR Form 252 or 272
Pictures of subjectand/or inventory / Mortgage interest info (if applicable)
Mortgage on Subject? Yes No
no
Tax statements for subject & comparable

Payment Packages

Item (RH, PP, Move, Incidental) / Item: RHPPMoveIncidental / Item: RHPPMoveIncidental / Item: RHPPMoveIncidental / Item: RHPPMoveIncidental
OK / NA / OK / NA / OK / NA / OK / NA
Cover sheet DR Form 285
Claim sheet DR Form 55
Assignment of payments DR Form 349 (may be several)
RHP computation DR Form 252 or 272
Rent receipt if applicable
Closing statement
Purchase agreement (accepted)
Mortgage payoff verification
Increased interest DR Form 506
Interest supporting documents (subject & replacement)
Tax differential DR Form 344
Tax statements (3) (subject, comparable and replacement)
Incidental expenses
DSSDR Form 60
Move receipts (if applicable)
Escrow funds (if not DSS)
Advanced warrants required

Call Reports Regarding All Significant Issues

Y / N / NA / Y / N / NA
Offers / Coordination of real estate closing for owners
Discuss relocation process with realtor / Type of move chosen by displacee
Your attendance at real estate closing / Coordination of move date & keys surrendered
Coordination of real estate closing / Discuss post-move problems with displacee
DSS inspection (subsequent ones if necessary) / Discuss with mover how they will be paid
Receipt of accepted offer on replacement or lease agreement / Disbursement of final relocation payment
Checking with displace on status of locating replacement housing / Discuss with displacee leaving property in good condition
Payment Eligibilities

Last Resort Housing: Yes No

Replacement Housing

Comp. / Replace / Subject / NA / Eligible Amount / NA / Paid Amount / NA / Date Paid
Purchase
Rent
Incidental Expenses
Interest Differential
1st Year Tax / Lump Sum
2nd Year Tax
3rd year Tax
Move Expense (enter amounts below from study)
NA / Eligible Amount / NA / Paid Amount / NA / Date Paid
Self Move ($)
Schedule (Rooms $) (PP$)
Commercial - Bid #1 ($) Bid #2 ($)
Other (Utility Hookups, Yellow page ads, Letterhead, etc.)
Other (Utility Hookups, Yellow page ads, Letterhead, etc.)
Searching
Re-establishment
Loss of Tangible P/P
In-Lieu

Important Dates

Date
Initiation of negotiations
Offer (relocation)
90 day notice
Notice of intent to acquire
Notice of displacement (within reasonabletime of offer)
Rent to keep vacant
DSS inspection of replacement
30 day notice
Date moved
Vacancy inspection
Keys obtained
Keys to property management
Appeal #1
Appeal #2
Opinion survey sent
Agent close-out / Signature / Date
Approved close-out / Signature / Date

Relocation records to be kept for 3 years (ROWManual - page14)

07-40, May 2010Version 1.00Checklist No. 07-40