Relocation Checklist
Name of Relocatee:______
Address from which displaced:Address of Permanent Replacement
______Property:______
______
Date of Initial Occupancy at File contains Racial/Ethnic
displacement dwelling: ______group classification:_____Yes _____No
Tenure:__Owner _____Tenant If tenant, file contains: NA
_____Age of all members of household
Parcel Number: ______Sex of all members of household
_____Income of all members of household
1.Relocation benefits were provided under:
Uniform Act ______
Section 104(d) ______
Optional Coverage ______
2.What caused displacement (e.g., acquisition, federally-funded code enforcement,
voluntary demolition)?
______
3.Date of Initial Contact by Agency______
Purpose of Contact: ______
Date of Personal Interview______
Date of Notice of Eligibility ______
Date of Initiations of Negotiations______
Date of Acquisition or Demolition______
Date of Displacement______
Date Occupied Replacement Property______
4.Did the displacee receive an ______actual or ______fixed moving expense payment?_____Yes ______No. If yes, review claim documentation and complete a:
a.Moving Expense Payment: Date Claim Filed______
Amount Claimed:______
Amount Paid______
Date(s) Claim Paid______Check Number(s)______
Evidence of Receipt of Payment in File? _____Yes_____No
Was Amount of Payment correct?_____Yes_____No
5.Were referrals to comparable replacement dwellings provided to the displacee?
____Yes(Number:) (Date of Initial Referral:______)
_____NoIs there documented justification for lack of referrals? NA
_____Yes _____No
Explain (e.g., person was informed of rights and waived comparables or non-Uniform Act relocation provides other reasonable benefits. If no comparables are available, describe here the method used to determine upper limit of replacement housing payment)______
______
______
6._____N/AFor Homeowners: Cost of Actual or Comparable Replacement Dwelling,
whichever is less: $______(1)
Cost of Acquired Dwelling $______(2)
Differential (Line 1-Line 2) $______(3)
Incidental Expenses $______(4)
Increased Interest Cost $______(5)
Sum of Lines 3,4, and 5 $______(6)
(if optional coverage complete question 8 also)
7._____N/AFor Renters, is there documentation displacee was offered choice of replacement housing payments under URA or Section 104(d)?______Yes ______No (For option coverage relocation skip to question
a._____N/A ForSection 104(d):
Was relocatee offered Certificate or Voucher with referral to Section 8 unit?
_____Yes Did the relocatee accept? _____Yes _____No If no, complete below:
(1) Monthly cost of replacement or comparable
dwelling, whichever is less$______
(2) Ability to pay$______
(3) Monthly need (line 1 minus line 2)$______
(4) Line 3 X 60 months =$______
b._____N/A For URA:
(1) Monthly cost of replacement or comparable
dwelling, whichever is less$______
(2) Monthly cost of displacement dwelling or
ability to pay, whichever is less$______
(3) Monthly need (line 1 minus line 2)$______
(4) Line 3 X 42 months=$______
8._____N/A Optional Coverage Relocation:
a. Indicate replacement housing payment received: $______
b. How did the relocation benefits under Optional Coverage differ from what would
have beendue if the relocation were subject to Uniform Act? (Note limits, condition
of payment, other differences, as appropriate): Consistent with relocation plan.
______
9.Replacement Housing Payment:Payment Dates, Amounts & Check Numbers in Notes
Date Claim Filed______
Amount Claimed______
Date Claim Paid______
Amount Paid______
Evidence of Receipt of Payment in File?______Yes _____No
10.Date Note & Deed of Trust Signed by Homeowner: ______
Date Note & Deed of Trust Recorded at Register of Deeds: ______
Book Number______Page Number(s)______
11.Site Visit by Reviewer:
a.Was the replacement dwelling inspected?
_____No
_____YesExterior appears to be standard:_____Yes_____No
Interior appears to be standard:______Yes_____No
b.Was the relocates interviewed?
_____No If no, why?______
_____YesRelocatee appeared aware of rights or indicated involved in choosing replacement dwelling?_____Yes _____No
Notes: #9 Above: