Form DI-382 Claim for Relocation Payments - Nonresidential

DEPARTMENT OF THE INTERIOR

OMB CONTROL NO.

CLAIM FOR RELOCATION PAYMENTS – NONRESIDENTIAL

1084-0010

(Public Law 91-646, as amended)

Expires

PROJECT/TRACT:

AGENCY:

ADDRESS:
DATE OF INITIATION OF NEGOTIATIONS:

SECTION I – TO BE COMPLETED BY CLAIMANT
INSTRUCTIONS: This form is for use in applying for payment of moving, storage, actual direct loss of property, search, and reestablishment expenses
or a payment in lieu of these expenses (42 USC 4622). The representative will explain the differences between types of payments and , if you wish,
will help you complete the forms. No payments will be made unless the forms are properly executed and received. If your claim is disapproved and/
or adjusted from the amounts claimed you will be provided a written explanation for the reason and steps that you may take to have your claim
reviewed, in accordance with regulations and procedures. NOTE: Actual expenses must be supported by receipts, vouchers, closing statements or
other documentation, or similar evidence remitted with the appropriate forms.
2. NAME/TITLE:
(person filing claim for claimant)

1. NAME:
(claimant)

MAILING ADDRESS:

MAILING ADDRESS:
TAX ID NO. OR SOCIAL SECURITY NO.:
TELEPHONE NUMBER: (

)

TELEPHONE NUMBER: (

3. TYPE OF CONCERN: BUSINESS ❑

FARM OPERATION ❑

4. TYPE OF OWNERSHIP: SOLE PROPRIETORSHIP ❑

)

NONPROFIT ORGANIZATION ❑

CORPORATION ❑

PARTNERSHIP ❑

NONPROFIT ORGANIZATION ❑

Please address only the category that describes your citizenship status. For item (2), please fill in the correct number of partners.
(49CFR24.208(a)) Your signature on this claim form constitutes certification.
(1) Sole Proprietorship – I certify that I am (check one) ___ a citizen or national of the United States; ___ an alien lawfully present in the
United States.
(2) Partnership – I certify that there are ____ partners in the partnership and that ____ are citizens or nationals of the United States and
____ are aliens lawfully present in the United States.
(3) Corporation – I certify that (Name of Corporation) __________________________ is established pursuant to State law and is authorized to
conduct business in the United States.
5. DATES YOU OCCUPIED THE PROPERTY: FROM __________ TO __________
6. DID CONCERN DISCONTINUE OPERATION? __________
7. DOES CONCERN PLAN TO REESTABLISH? __________
8. DATE YOU OCCUPIED THE REPLACEMENT: __________
9. ADDRESS OF REPLACEMENT:

10. TYPE OF CLAIM:
11. TYPE OF PAYMENT:

INITIAL ❑
ACTUAL ❑

SUPPLEMENTARY ❑ FINAL ❑
FIXED PAYMENT (complete item 13 on reverse) ❑

12. CLAIM:
MOVING AND STORAGE EXPENSES (Attach completed schedule A)

AMOUNT

FOR AGENCY USE ONLY

$

$

ACTUAL DIRECT LOSSES OF PROPERTY (Attach completed schedule B) $

$

REASONABLE SEARCH EXPENSES (Attach completed schedule C)

$

$

REESTABLISHMENT EXPENSES (Attach completed schedule D)

$

$

FIXED PAYMENT

$

$
DI-382 1
(04/15)

13. FIXED PAYMENT IN LIEU OF ACTUAL EXPENSES:
FOR BUSINESS OR FARM OPERATION

FOR NONPROFIT ORGANIZATION

What were the annual net earnings, including compensation to owner, the
owner’s spouse and dependents, before Federal, State, and local income
taxes for the two taxable years immediately prior to the taxable year of
displacement. (Proof of net earnings shall be furnished through income tax
returns, certified financial statements or other evidence.)
TAX YEAR: ______
NET EARNINGS:
$ ____________

TAX YEAR: ______

PERIOD: ____________ PERIOD: ____________

AVERAGE
AMOUNT

NET EARNINGS:
$ ____________

What were the annual gross revenues, less administrative expenses for the two
12-month periods prior to acquisition? (Certified financial statements or financial
documents must be provided for any payment in excess of $1000.)

AMOUNT

AVERAGE
AMOUNT

AMOUNT

$ ____________ $ ____________ $ __________

$ __________

Name(s) used on income tax return(s) or other acceptable proof of
income:

Is organization incorporated under applicable laws of a

Employer identification number(s) shown on tax return(s)
(if tax returns used as proof of income):

Is organization exempt from paying Federal income
taxes under section 501 of the Internal
Revenue Code (26 U.S.C. 501)?
YES ❑

State as a nonprofit organization?

YES ❑

NO ❑

NO ❑

14. NAME AND ADDRESS OF PERSON(S)
TO WHOM PAYMENTS ARE TO BE MADE:

15. CERTIFICATION: I (We) CERTIFY under the penalties and provisions of U.S.C. Title 18, Sections 286, 287, 1001, and any other applicable law, that this claim and
information submitted herewith have been examined by me (us) and are true, correct, and complete. I (We) further certify that I (We) have not submitted any other
claim for, or received reimbursement or compensation from any other source for any item of this claim; and that any receipts submitted herewith accurately reflect costs
actually incurred. I (We) further certify that my (our) choice of type of payment was made on the basis of a full explanation by the displacing agency representative of
the differences between the types of payments available.

SIGNATURE: ___________________________________________________
(claimant or agent)

SIGNATURE: ___________________________________________________

DATE: _________________________________________________________

DATE: __________________________________________________________

PRIVACY ACT STATEMENT: 42 U.S.C. 4601 et seq. authorizes collection of this information. The primary use of the information is to determine whether the claimant
is eligible for and entitled to relocation benefits. Furnishing the information is required in order to process your claim. The information may also be provided to appropriate Federal, State, local or foreign agencies responsible for investigating or prosecuting a violation of law; to the Department of Justice when relevant to litigation or
anticipated litigation.
PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et. seq.) requires the public to be informed that this
Information is being collected in order to assess claims for relocation expenses. Completion of this form, including gathering of needed information, is estimated to
take 50 minutes. Public comments on this estimate or suggestions for reducing this information collection burden should be directed to the Office of Acquisition and
Property Management, U.S. Department of the Interior, MS 4262-MIB, Washington DC 20240. Submission of this form is necessary to obtain a government benefit.
A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.
PENALTY FOR FALSE OR FRAUDULENT STATEMENT: U.S.C. Title 18, 1001, provides: ‘Whoever, in any matter within the jurisdiction of any department or agency
of the United States knowingly and willfully falsifies . . . or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or
document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years
or both.

SECTION II – TO BE COMPLETED BY AGENCY
AMOUNT PREVIOUSLY PAID (if any)..... $ __________________
PAYMENT
RECOMMENDED:
APPROVED:
FBMS INVOICE NO.:

SIGNATURE

TITLE

DATE

___________________

_____________________________________________

___________________

___________________

___________________

_____________________________________________

___________________

___________________

AMOUNT

___________________
DI-382 2

SCHEDULE A
MOVING AND RELATED COSTS – NONRESIDENTIAL
(Under Sec. 202, P.L. 91-646, as amended)

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

3. TYPE OF MOVE:

2. PROJECT/TRACT:

SELF ❑

COMMERCIAL ❑

SELF AND COMMERCIAL ❑

4. MOVING COSTS: (See reverse for allowable/nonallowable expenses)
ITEM

CONTRACTOR/ADDRESS/PHONE NUMBER

AMOUNT CLAIMED

FOR AGENCY USE ONLY

MOVING: .....................................................................................................................

$

$

ELECTRICAL: ............................................................................................................

$

$

MECHANICAL: ...........................................................................................................

$

$

PLUMBING: ................................................................................................................

$

$

CARPENTRY: .............................................................................................................

$

$

OTHER: (list) ..............................................................................................................

$

$

__________ ...............................................................................................................

$

$

__________ ...............................................................................................................

$

$

__________ ...............................................................................................................

$

$

TOTAL ...........................................................

$

0.00

$

0.00

5. STORAGE COSTS:
TYPE OF CLAIM:

INITIAL ❑

SUPPLEMENTARY ❑

FINAL ❑

NAME AND ADDRESS OF STORAGE COMPANY:

STORAGE PERIOD: NUMBER OF MONTHS ______, ARE THE NUMBER OF MONTHS
DATE PROPERTY WAS MOVED: TO STORAGE ___________________________;

ACTUAL ❑

OR ESTIMATED ❑

FROM STORAGE ______________________________

STORAGE COSTS: $ _____________
DESCRIPTION OF PROPERTY STORED: (List each major item separately or attach a Bill of Lading from the moving company showing the
items stored.)

DI-382 3

6. REMARKS:

7. SIGNATURE:

SIGNATURE:
___________________________________________

DATE: ___________________________________________

___________________________________________
DATE:

___________________________________________

SECTION II – TO BE COMPLETED BY AGENCY
MOVING ESTIMATE OBTAINED BY THE AGENCY:

$ ____________________

MOVING COSTS:

$ ____________________

STORAGE COSTS:

$ ____________________

ADVANCE RECEIVED (if any):

$ ____________________

PAYMENT

SIGNATURE

AMOUNT

TITLE

DATE

RECOMMENDED:

___________________

_____________________________________________

___________________

________________

APPROVED:

___________________

_____________________________________________

___________________

________________

FBMS INVOICE NO.: ___________________
ALLOWABLE MOVING EXPENSES
1. Transportation of personal property not to exceed 50 miles except
where the Agency determines that relocation beyond the 50-mile
Area is justified.
2. Packing, crating, unpacking and uncrating personal property.
3. Disconnecting, dismantling, removing, reassembling and
reinstalling relocated machinery, equipment and other personal
property, including substitute personal property.
4. Storage of the personal property for a period not to exceed
12 months, unless the Agency determines that a longer period is
necessary.
5. Insurance for the replacement value of the personal property in
connection with the move and necessary storage.
6. Any license, permit, or certification required of the displaced person
at the replacement location. However, the payment may be based
on the remaining useful life of the existing license, permit, fees or
certification.
7. The replacement value of property lost, stolen, or damaged in the
process of moving (not through the fault or negligence of the
displaced person, his or her agent or employee) where insurance
covering such loss, theft, or damage is not reasonably available.
8. Professional services determined to be actual, reasonable and
necessary for planning, moving and installing relocated personal
property at the replacement location.

9. Relettering signs and replacing stationery on hand at the time of
displacement and making updates to other media that are made
obsolete as a result of the move.
10. Purchase of substitute personal property.
1 1. Payment for low value/high bulk personal property.
12. Connection to available nearby utilities from the right-of-way to
improvements at the replacement site.
13. Professional services performed prior to the purchase or lease of a
replacement site to determine its suitability for the displaced person’s
business operation including but not limited to, soil testing, feasibility
and marketing studies (excluding any fees or commissions directly
related to the purchase or lease of such site). At the discretion of the
Agency a reasonable pre-approved hourly rate may be established.
(See appendix A, § 24.303(b).)
14. Impact fees or one time assessments for anticipated heavy utility
usage, as determined necessary by the Agency.
15. Other moving-related expenses that are not listed as ineligible under
Nonallowable Moving Expenses as the Agency determines to be
reasonable and necessary.

NONALLOWABLE MOVING EXPENSES
1. Cost of moving any structures of other real property improvement in
which the displaced person reserved ownership.
2. Interest on loan to cover moving expenses.
3. Loss of goodwill.
4. Loss of profits.
5. Loss of trained employees.
6. Additional operating expenses incurred because of operating in a
new location except as specifically provided for.

7. Personal injury.
8. Any legal fee or other cost for preparing a claim for a relocation
payment or for representing the claimant before the Agency.
9. Physical changes to the real property at the replacement location
except as specifically provided for.
10. Costs for storage of personal property on real property already owned
or leased by the displaced person.
11. Refundable security and utility deposits.

DI-382 4

SCHEDULE B
DIRECT LOSS OF PERSONAL PROPERTY – NONRESIDENTIAL
(Under Sec. 202, P.L. 91-646, as amended)

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

2. PROJECT/TRACT:

3. TANGIBLE PERSONAL PROPERTY:
ITEM
(list)

FAIR MARKET VALUE
FOR CONTINUED USE
AT PRESENT LOCATION

-

NET PROCEEDS
FROM SALE

=

VALUE NOT
RECOVERED
BY SALE

FOR AGENCY
USE ONLY

1.

$

$

$

0.00

$

2.

$

$

$

0.00

$

3.

$

$

$

0.00

$

4.

$

$

$

0.00

$

5.

$

$

$

0.00

$

6.

$

$

$

0.00

$

7.

$

$

$

0.00

$

8.

$

$

$

0.00

$

COST OF SALE: ...............................................................................................................

$

TOTAL: ................................................................................................................................

$

$

0.00

$

0.00

Actual direct loss of tangible personal property incurred as a result of moving or discontinuing the business or farm operation. The payment shall consist
of the lesser of: (i)The fair market value in place of the item, as is for continued use, less the proceeds from its sale. (To be eligible for payment, the
claimant must make a good faith effort to sell the personal property, unless the Agency determines that such effort is not necessary. When payment
for property loss is claimed for goods held for sale, the market value shall be based on the cost of the goods to the business, not the potential selling
prices.); or (ii) The estimated cost of moving the item as is, but not including any allowance for storage; or for reconnecting a piece of equipment if the
equipment is in storage or not being used at the acquired site. If the business or farm operation is discontinued, the estimated cost of moving the item
shall be based on a moving distance of 50 miles. The reasonable cost incurred in attempting to sell an item that is not to be relocated.
4. REMARKS: (Use other side if necessary)

5. RELEASE: I (We) hereby release to the displacing agency ownership and title to all personal property remaining on the acquired site, for which
the claimant has received or will receive a payment for direct loss of property.
SIGNATURE:

SIGNATURE:

DATE:

DATE:

SECTION II – TO BE COMPLETED BY AGENCY
TOTAL COSTS ...............................................................................................................................

$ _____________________

ESTIMATED COSTS OF MOVING PROPERTY............................................................................

$ _____________________

AMOUNT

SIGNATURE

RECOMMENDED:

________________

______________________________________

____________________

_____________

APPROVED:

________________

______________________________________

____________________

_____________

PAYMENT

TITLE

DATE

FBMS INVOICE NO.: ________________
DI-382 5

SCHEDULE C
SEARCH EXPENSES – NONRESIDENTIAL
(Under Sec. 202, P.L. 91-646, as amended)

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

2. PROJECT/TRACT:

3. ACTUAL EXPENSES:

AMOUNT CLAIMED

FOR AGENCY USE ONLY

SEARCHING TIME ........ ______ (hours) at ______ (rate) ................................... $

0.00

$

TRANSPORTATION ....... ______ (miles) at ______ (rate) ................................... $

0.00

$

LODGING ...................... ______ (nights) at ______ (rate) ................................... $

0.00

$

COST OF MEALS ....................................................................................................... $

$

TIME SPENT IN OBTAINING PERMITS
AND ATTENDING ZONING HEARINGS. ....... ______ (hours) at ______ (rate) ...... $

0.00

$

TIME SPENT NEGOTIATING THE
PURCHASE OF A REPLACEMENT SITE ..... ______ (hours) at ______ (rate) ...... $

0.00

$

FEES PAID TO REAL ESTATE AGENTS OR BROKERS (excluding commissions) . $

$

OTHER (list) ............................................................................................................... $

$

.................................................................................................................................... $

$

TOTAL ......................................................................................................................... $

$

0.00

0.00

4. REMARKS:

5. SIGNATURE:

SIGNATURE:
___________________________________________

DATE: ___________________________________________

___________________________________________
DATE:

___________________________________________

SECTION II – TO BE COMPLETED BY AGENCY

PAYMENT

AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

___________________

_____________________________________________

___________________

________________

APPROVED:

___________________

_____________________________________________

___________________

________________

FBMS INVOICE NO.: ___________________
DI-382 6

SCHEDULE D
REESTABLISHMENT EXPENSES – NONRESIDENTIAL
(Under Sec. 202. P.L. 91-646, as amended)

SECTION I – TO BE COMPLETED BY CLAIMANT
1. NAME:

2. PROJECT/TRACT:

3. REESTABLISHMENT EXPENSES: (See reverse for allowable/nonallowable expenses)
ITEM (list)

AMOUNT CLAIMED

FOR AGENCY USE ONLY

1. ......................................................................................

$

$

2. ......................................................................................

$

$

3. ......................................................................................

$

$

4. ......................................................................................

$

$

5. ......................................................................................

$

$

6. ......................................................................................

$

$

7. ......................................................................................

$

$

8. ......................................................................................

$

$

9. ......................................................................................

$

$

10. ......................................................................................

$

$

11. ......................................................................................

$

$

12. ......................................................................................

$

$

13. ......................................................................................

$

$

14. ......................................................................................

$

$

TOTAL ..................................................................................

$

0.00

$

0.00

4. REMARKS:

5. SIGNATURE:

SIGNATURE:
___________________________________________

DATE: ___________________________________________

___________________________________________
DATE:

___________________________________________

DI-382 7

SECTION II – TO BE COMPLETED BY AGENCY
REESTABLISHMENT EXPENSES ........................

$ ________________

ADVANCE RECEIVED (if any) ..............................

$ ________________

PAYMENT

AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

___________________

_____________________________________________

___________________

________________

APPROVED:

___________________

_____________________________________________

___________________

________________

FBMS INVOICE NO.: ___________________
REMARKS:

REESTABLISHMENT EXPENSES CAN ONLY BE PAID TO A BUSINESS HAVING NOT MORE THAN 500 EMPLOYEES WORKING AT THE
SITE ACQUIRED OR DISPLACED BY A PROGRAM OR PROJECT, WHICH SITE IS THE LOCATION OF ECONOMIC ACTIVITY OR A FARM OR
NONPROFIT ORGANIZATION. 49CFR24.2(a)(24)
ELIGIBLE EXPENSES

INELIGIBLE EXPENSES

1. Repairs or Improvements to the replacement property as required
by Federal, State, or local law, code or ordinance.

1. Purchase capital assets, such as office furniture, filing cabinets,
machinery, or trade fixtures.

2. Modifications to the replacement property to accommodate the
business operation or make replacement structures suitable for
conducting the business.

2. Purchase of manufacturing materials, production supplies,
product inventory, or other items used in the normal course of the
business operation.

3. Construction and installation costs for exterior signing to
advertise the business.

3. Interest on money borrowed to make the move or purchase the
replacement property.

4. Redecoration or replacement of soiled or worn surfaces, such as
paint, paneling, or carpeting.

4. Payment to a part time business in the home which does not
contribute materially to the household income.

5. Licenses, fees and permits when not paid as part of moving
expenses.
6. Advertisement of replacement location.
7. Estimated increased costs of operation during the first two years
at the replacement site for such items as lease or rental charges,
personal or real property taxes, insurance premiums and utility
charges (excluding impact fees).
8. For businesses, farms or nonprofit organizations this includes
machinery, equipment, substitute personal property, and
connections to utilities available within the building; it also
includes modifications to the personal property, including those
mandated by Federal, State or local law, code or ordinance,
necessary to adapt it to the replacement structure, the
replacement site, or the utilities at the replacement site, and
modifications necessary to adapt the utilities at the replacement
site to the personal property.
9. Other items that the Agency considers essential to the
reestablishment of the business.

DI-382 8