Form DI-381 Claim for Relocation Payments - Residential - Main

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:

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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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