Form DI-381 Claim for Relocation Payments - Residential

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

DI-381 (03-2019)
Department of the Interior

CLAIM FOR RELOCATION PAYMENTS – RESIDENTIAL
(Public Law 91-646, as amended)

AGENCY:

PROJECT/TRACT:
ADDRESS:

DATE OF INITIATION OF NEGOTIATIONS:

Section 1 – To Be Completed By Claimant
INSTRUCTIONS: This form is for use in applying for payment of moving costs (42 USC 4622); homeowners replacement housing payment; rental
replacement housing payment and down payment and incidental expenses. 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 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 form.
1. NAME:
MAILING ADDRESS:
SOCIAL SECURITY NUMBER:
TELEPHONE NUMBER: (

)

Please address only the category (individual or family) that describes your occupancy status. For item (2), please fill in the correct number of
persons. (49CFR24.208(a)). Your signature on this claim form constitutes certification.
(1) Individual – I certify that I am: (check one) ____ a citizen or national of the United States; ____ an alien lawfully present in the United States.
(2) Family – I certify that there are ____ persons in my household and that ____ are citizens or nationals of the United States and
____ are aliens lawfully present in the United States.
2. DID YOU OCCUPY THE AGENCY ACQUIRED DWELLING? IF YES; PERMANENT ❑ OR SEASONAL ❑
3. WERE YOU A: HOMEOWNER OCCUPANT ❑ OR: TENANT ❑ OR: SLEEPING ROOM TENANT ❑
4. DATE YOU PURCHASED THE AGENCY ACQUIRED DWELLING:
5. DATE YOU RENTED THE AGENCY ACQUIRED DWELLING:
6. DATE YOU MOVED INTO THE AGENCY ACQUIRED DWELLING:
7. DATE YOU MOVED FROM THE AGENCY ACQUIRED DWELLING:
8. WAS IT FURNISHED WITH YOUR OWN FURNITURE?
9. NUMBER OF ROOMS: (exclude bathrooms, closets, hallways)
10. LIST ALL MEMBERS OF THE HOUSEHOLD BY NAME, GENDER, RELATIONSHIP, AGE, AND DISABILITY IF ANY:

11. ADDRESS OF REPLACEMENT DWELLING: (To which you moved)

12. DATE YOU PURCHASED THE REPLACEMENT DWELLING:
13. DATE YOU RENTED THE REPLACEMENT DWELLING:
14. DATE YOU MOVED INTO THE REPLACEMENT DWELLING:

Page 1 of 9

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

15. CLAIM
MOVING COSTS (Attach completed Schedule A)

AMOUNT

FOR AGENCY USE ONLY

$ _______________________

$ ___________________________________

REPLACEMENT HOUSING PAYMENT; HOMEOWNERS $ _______________________
(Attach completed schedule B)

$ ___________________________________

RENTAL REPLACEMENT HOUSING PAYMENT
(Attach completed Schedule C)

$ _______________________

$ ___________________________________

DOWN PAYMENT AND INCIDENTAL EXPENSES
(Attach completed Schedule D)

$ _______________________

$ ___________________________________

16. 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: __________________________________________

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.
RECORDS RETENTION. TEMPORARY. Destroy 7 years after final action, but longer retention is authorized if required for business use. (DAA-0048-2013-0001-0011)

Section 2 – To Be Completed By Agency
CERTIFICATION BY DISPLACING AGENCY: l certify that the above named claimant’s replacement dwelling located at
_________________________ in the County of __________________________________ and State of ________________________ was
inspected on _______________________ by _________________________________ and was determined to be decent, safe, and sanitary.

__________________________________________________
SIGNATURE

________________________________________________________________
INSPECTING OFFICIAL’S NAME AND TITLE

REMARKS:

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DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Schedule A
Payment of Moving Costs – Residential
(Under Sec. 202, P.L.91-646, as amended)

Section 1 – To Be Completed By Claimant
1. NAME:
3. TYPE OF
PAYMENT
CLAIMED:

2. PROJECT/TRACT:
FIXED PAYMENT
❑
$ _____________

REIMBURSEMENT FOR ACTUAL EXPENSE
(Complete item 4 including storage costs if applicable)
❑

SUPPLEMENTARY CLAIM FOR
REIMBURSEMENT OF STORAGE
COSTS (Complete item 5)
❑

4. ACTUAL MOVING EXPENSES (Supported by receipted bills for labor and equipment.)
(See reverse for allowable/non-allowable)
FOR AGENCY USE ONLY

ITEM

AMOUNT CLAIMED

MOVING COSTS

$ _______________

$ ___________________________________

TRANSPORTATION COSTS-FAMILIES AND INDIVIDUALS (if any) $ _______________

$ ___________________________________

COST OF INSURANCE COVERING MOVE AND/OR STORAGE

$ _______________

$ ___________________________________

STORAGE COSTS (Complete item 5)

$ _______________

$ ___________________________________

OTHER (Explain on reverse under remarks)

$ _______________

$ ___________________________________

TOTAL AMOUNT OF CLAIM

0.00
$ _______________

0.00
$ ___________________________________

AMOUNT OF ADVANCE PAYMENT(S) RECEIVED (if any)

$ _______________

$ ___________________________________

TOTAL AMOUNT (less advance, if any)

0.00
$ _______________

0.00
$ ___________________________________

5. CLAIM FOR STORAGE COSTS: (Complete only if personal property was moved to or from storage)
TYPE OF CLAIM:

INITIAL ❑

SUPPLEMENTARY ❑

FINAL ❑

DATE PROPERTY WAS MOVED
TO STORAGE: __________________
FROM STORAGE: _______________

STORAGE PERIOD: NUMBER OF MONTHS ______, ARE THE NUMBER OF MONTHS
STORAGE COSTS:

TOTAL COST INCURRED
$ ___________________

ACTUAL ❑

AMOUNT PREVIOUSLY RECEIVED
-

$ ____________________________

OR: ESTIMATED ❑

TOTAL AMOUNT
=

0.00
$ ___________________

6. METHOD OF PAYMENT: (Check one)
___ l (We) request the fixed payment.
___ I (We) have paid the moving costs itemized above and, therefore, request reimbursement.
___ I (We) have not paid the moving costs itemized above and, therefore, request payment be made directly to the mover and/or storage
company or other contractors, in accordance with arrangements made in advance, and with my (our) consent, between the agency and the
mover and/or storage company or other contractors.
___ I (We) hereby request and authorize the moving costs to be incurred, be paid directly to the mover and/or storage company or other
contractors, in accordance with arrangements made at this time, and with my (our) consent, between the agency and the mover and/or
storage company or other contractors.
7.
SIGNATURE: _________________________________________

SIGNATURE: __________________________________________

DATE: _______________________________________________

DATE: ________________________________________________

Page 3 of 9

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Section 2 – To Be Completed By Agency
MOVING EXPENSE:

$ ____________________

ADVANCE RECEIVED:

$ ____________________

TOTAL AMOUNT:

0.00
$ ____________________

PAYMENT AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

_________________

________________________________________

_________________

______________

APPROVED:

_________________

________________________________________

_________________

______________

FBMS INVOICE NO.:_________________
REMARKS:

ALLOWABLE MOVING EXPENSES
1. Transportation of individuals, families, and personal property from
the acquired site to the replacement site not to exceed 50 miles,
except where the displacing agency determines that relocation
beyond this 50 mile area is justified.
2. Packing and unpacking, crating and uncrating of personal property.
3. Disconnecting, dismantling, removing, reassembling, and reinstalling
relocated household appliances, and other personal property.
4. Storage of 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 property in connection
with the move and necessary storage.
6. 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.

7. The reasonable cost of disassembling, moving, and reassembling
any appurtenances attached to a mobile home, such as porches,
decks, skirting, and awnings, which were not acquired, anchoring of
the unit, and utility ‘‘hookup’’ charges.
8. The reasonable cost of repairs and/or modifications so that a mobile
home can be moved and/or made decent, safe, and sanitary.
9. The cost of a nonrefundable mobile home park entrance fee, to the
extent it does not exceed the fee at a comparable mobile home
park, if the person is displaced from a mobile home park or it is
determined that payment of the fee is necessary to effect relocation.
10. Other moving-related expenses that are not listed as ineligible under
Non-allowable Moving Expenses, as the Agency determines to be
reasonable and necessary.

NON-ALLOWABLE MOVING EXPENSES
1. Cost of moving structures or other real property improvements in
which the displaced person reserved ownership.
2. Interest on loan to cover moving expenses.
3. Additional expenses incurred because of living in a new location.
4. Personal injury
5. Any legal fee or other cost for preparing a claim for relocation
payment or for representing the claimant before the agency.

6. Expenses for searching for a replacement dwelling.
7. Physical changes to the real property at the replacement location.
8. Costs for storage of personal property on real property already
owned or leased by the displaced person.
9. Refundable security and utility deposits.

Page 4 of 9

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Schedule B
Claim of Home Owners Replacement Housing Payments – Residential
(Under Sec. 204 (a), P.L.91-646, as amended)

Section 1 – To Be Completed By Claimant
1. NAME:

2. PROJECT/TRACT:

3. At the time you received the Agency’s written offer to acquire your dwelling, was this dwelling owned and occupied by you for 90 consecutive
days immediately prior thereto as your permanent residence? YES ❑ NO ❑
4. INCIDENTAL EXPENSES: (Attach a copy of the closing statement and/or other documentation in support of the amounts claimed
(49CFR24.401(e))
ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

LEGAL, CLOSING , AND
RELATED COSTS

$ __________

______________

ESCROW FEE

$ __________

______________

TITLE SEARCH FEE

$ __________

______________

TRANSFER TAXES

$ __________

______________

NOTARY FEE

$ __________

______________

$ __________

______________

RECORDING FEES

$ __________

______________

LOAN ORIGINATION OR
ASSUMPTION FEES (that do
not represent prepaid interest)

SURVEY COSTS

$ __________

______________

CERTIFICATION FEE

$ __________

______________

LENDER’S APPRAISAL FEE

$ __________

______________

HOME INSPECTION FEE

$ __________

______________

LENDER’S APPLICATION FEE $ __________

______________

TERMITE INSPECTION FEE

$ __________

______________

CREDIT REPORT FEE

$ __________

______________

OTHER (LIST) ___________

$ __________

______________

OWNER’S AND MORTGAGEE’S $ __________
EVIDENCE OF TITLE

______________

_______________________

$ __________

______________

_______________________

$ __________

______________

TOTAL

0.00
$ __________

0.00
______________

5. AMOUNT OF RENTAL ASSISTANCE PAYMENT PREVIOUSLY RECEIVED (if any)
6. AMOUNT OF REPLACEMENT HOUSING PAYMENT ADVANCED (if any)

$ ______________________

$ ____________________________

SIGNATURE: ____________________________________________

SIGNATURE: ___________________________________________

DATE: _________________________________________________

DATE: _________________________________________________

Section 2 – To Be Completed By Agency
COMPUTATION OF AMOUNT OF PAYMENT
LAST RESORT HOUSING PAYMENT

YES ❑

NO ❑

PRICE OF A COMPARABLE DWELLING:

$ _______________

MORTGAGE INTEREST COST: (See note) $ ________________
AMOUNT OF INCIDENTAL EXPENSES

$ ________________

PRICE PAID FOR REPLACEMENT DWELLING: $ _______________

TOTAL PAYMENT:

$ ________________

PRICE PAID FOR ACQUIRED DWELLING:

AMOUNTS PREVIOUSLY PAID OR
ADVANCED:

$ ________________

TOTAL DUE UNDER THIS CLAIM:

0.00
$ ________________

PAYMENT: (The lesser of the difference
between the comparable and acquired OR
the replacement and acquired dwelling)

$ _______________

$ _______________

Note: Increased mortgage interest costs can be claimed only if there was a bona fide mortgage(s) on the acquired dwelling for at least 90 days
immediately prior to the initiation of negotiations to acquire the property.

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DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021
COMPUTATION OF INCREASED MORTGAGE INTEREST COSTS
AGENCY ACQUIRED DWELLING MORTGAGE(S)

REPLACEMENT
DWELLING
MORTGAGE
(b)

(a)
ITEM

FIRST

SECOND

THIRD

1. ISSUANCE DATE OF MORTGAGE
2. OUTSTANDING MORTGAGE BALANCE

$

$

$

$

3. AMOUNT OF MONTHLY MORTGAGE
PAYMENT

$

$

$

$

4. ANNUAL INTEREST RATE OF MORTGAGE

%

%

%

%

5. MONTHS REMAINING ON MORTGAGE
BALANCE: .....................................................
6. MONTHLY PAYMENTS OF:.. (line 3) ............

$

0.00

$

0.00

0.00

$

At the current prevailing fixed interest rate

7. FOR NUMBER OF MONTHS ... (line 5) .......
8. WILL PAY OFF A BALANCE OF: ...................

$

$

9. INTEREST DIFFERENTIAL PAYMENT FOR
EACH MORTGAGE: .....................................
(line 2 minus line 8)

$

10. SUM OF PAYMENTS TO EACH
MORTGAGE: .....................................
(from line 9, but not less than 0)

$ ___________

11. COST OF POINTS FOR MORTGAGE:

$ ___________

12. TOTAL:

$ ___________

0.00

$

$

0.00

0.00

$

13. IF line 2(b) IS LESS THAN THE TOTAL OF line 8 THEN:
_________ - _____________ = ______________ x ___________ = ___________
line 2(b)
total of line 8
factor
line 12
total
REMARKS:

PAYMENT

AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

_________________

________________________________________

_________________

______________

APPROVED:

_________________

________________________________________

_________________

______________

FBMS INVOICE NO.:_________________

Page 6 of 9

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Schedule C
Claim of Rental Replacement Housing Payments – Residential
(Under Sec. 204 (a), P.L.91-646, as amended)

Section 1 – To Be Completed By Claimant
1. NAME:

2. PROJECT/TRACT:

3. WHAT WAS THE MONTHLY RENTAL RATE OF THE

4. CHECK THE UTILITIES THAT WERE INCLUDED IN YOUR RENT:
❑ ELECTRIC

DWELLING YOU VACATED? $_________________

❑ GAS

❑ WATER

❑ OTHER

5. WHAT IS YOUR AVERAGE HOUSEHOLD MONTHLY INCOME? $ _________________
(Does not include income received or earned by dependent children and full time students under 18 years of age.) (49CFR24.2(a)(14))
6. WHAT IS THE MONTHLY RENTAL RATE FOR THE

7. CHECK THE UTILITIES THAT ARE INCLUDED IN YOUR RENT:
❑ ELECTRIC

REPLACEMENT DWELLING? $__________________
8. REQUEST FOR
PAYMENT:

❑ GAS

❑ WATER

❑ OTHER

LUMP SUM

INSTALLMENT

FREQUENCY

❑

❑

_____________

AMOUNT OF
INSTALLMENT
$_____________

9.
SIGNATURE: ___________________________________________ SIGNATURE:
DATE: ___________________________________________

DATE:

___________________________________________
___________________________________________

Section 2 – To Be Completed By Agency
COMPUTATION OF AMOUNT OF PAYMENT
LAST RESORT HOUSING PAYMENT

YES ❑

BASE MONTHLY RENTAL OF COMPARABLE REPLACEMENT DWELLING:

$ _______________

BASE MONTHLY RENTAL RATE OF REPLACEMENT DWELLING:

$ _______________

BASE MONTHLY RENTAL RATE OF ACQUIRED DWELLING:
(actual rent or 30% of line 5, whichever is less) (49CFR24.402(b)(2)(ii))

$ _______________

REPLACEMENT RENTAL COSTS:
(The lesser of the difference between the comparable and acquired
OR the replacement and acquired)

$ ________________

AMOUNT DUE UNDER THIS CLAIM:
(Replacement rental costs multiplied by 42)

$ ________________

PAYMENT

AMOUNT

NO ❑

SIGNATURE

TITLE

DATE

RECOMMENDED:

_________________

________________________________________

_________________

______________

APPROVED:

_________________

________________________________________

_________________

______________

FBMS INVOICE NO.:_________________
REMARKS:

Page 7 of 9

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Schedule D
Down Payment and Incidental Expenses – Residential
(Under Sec. 204 (b) P.L. 91-646, as amended)

Section 1 – To Be Completed By Claimant
1. NAME:

2. PROJECT/TRACT:

3. PRICE PAID FOR REPLACEMENT DWELLING:

$ __________________

4. DOWN PAYMENT ACTUALLY PAID FOR REPLACEMENT DWELLING:

$ __________________

5. INCIDENTAL EXPENSES: (Attach a copy of the closing statement and/or other documentation in support of the amounts claimed)
49CFR24.401(e)
ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

ITEM

AMOUNT
CLAIMED

FOR AGENCY
USE ONLY

LEGAL, CLOSING, AND
RELATED COSTS

$ __________

______________

ESCROW FEE

$ __________

______________

TITLE SEARCH FEE

$ __________

______________

TRANSFER TAXES

$ __________

______________

NOTARY FEE

$ __________

______________

$ __________

______________

RECORDING FEES

$ __________

______________

LOAN ORIGINATION OR
ASSUMPTION FEES (that do
not represent prepaid interest)

SURVEY COSTS

$ __________

______________

CERTIFICATION FEE

$ __________

______________

LENDER’S APPRAISAL FEE

$ __________

______________

HOME INSPECTION FEE

$ __________

______________

LENDER’S APPLICATION FEE $ __________

______________

TERMITE INSPECTION FEE

$ __________

______________

CREDIT REPORT FEE

$ __________

______________

$ __________

______________

OWNER’S AND MORTGAGEE’S $ __________
EVIDENCE OF TITLE

______________

COST OF POINTS
FOR MORTGAGE
OTHER (LIST) ___________

$ __________

______________

_______________________

$ __________

______________

_______________________

$ __________

______________

TOTAL

0.00
$ __________

0.00
______________

6. RENTAL ASSISTANCE PAYMENT PREVIOUSLY RECEIVED: (if any)
7. DOWN PAYMENT ADVANCED: (if any)

$ __________________

$ __________________

8.
SIGNATURE: ___________________________________________ SIGNATURE:
DATE: ___________________________________________

DATE:

___________________________________________
___________________________________________

9. REMARKS:

Page 8 of 9

DI-381 (03-2019)
Department of the Interior

OMB Control Number: 1084-0010
Expiration Date: 12/31/2021

Section 2 – To Be Completed By Agency
COMPUTATION OF AMOUNT OF DOWN PAYMENT
PRICE OF A COMPARABLE DWELLING:

$ _______________

DOWN PAYMENT REQUIRED FOR
CONVENTIONAL MORTGAGE ON
COMPARABLE DWELLING:

$ _______________

PRICE PAID FOR REPLACEMENT DWELLING: $ _______________

TOTAL DOWN PAYMENT: (The lesser
of the difference between the
down payment for comparable plus
incidental costs or the down payment
actually paid plus incidental costs)

$ _______________

RENTAL ASSISTANCE
PREVIOUSLY RECEIVED:

$ ________________

DOWN PAYMENT ACTUALLY PAID
ON REPLACEMENT DWELLING:

$ _______________

DOWN PAYMENT ADVANCED:

$ ________________

INCIDENTAL COSTS:

$ _______________

TOTAL AMOUNT DUE:

$ ________________

PAYMENT

AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

_________________

________________________________________

_________________

______________

APPROVED:

_________________

________________________________________

_________________

______________

FBMS INVOICE NO.:_________________

Page 9 of 9