Form DI-382 Claim for Relocation Payments - Nonresidential - Main

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

DI-382 (03 -2019)
Department of the Interior

CLAIM FOR RELOCATION PAYMENTS – NONRESIDENTIAL
(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, 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.
1. NAME:
(claimant)

2. NAME/TITLE:
(person filing claim for 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:

AMOUNT

FOR AGENCY USE ONLY

MOVING AND STORAGE EXPENSES (Attach completed schedule A)

$

$

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 - Page 1 of 2

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

DI-382 (03 -2019)
Department of the Interior
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.)

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.)

TAX YEAR: ______

TAX YEAR: ______

NET EARNINGS:

NET EARNINGS:

AVERAGE
AMOUNT

$ ____________

$ ____________

$ _____________

PERIOD: _____________

PERIOD:______________

AMOUNT

AMOUNT

AVERAGE
AMOUNT

$ ____________

$ ____________

$ __________

Is organization incorporated under applicable laws of a
State as a nonprofit organization?
YES ❑
NO ❑

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

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 ❑

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.
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
AMOUNT PREVIOUSLY PAID (if any)..... $ ___________________
PAYMENT

AMOUNT

SIGNATURE

TITLE

DATE

RECOMMENDED:

_________________

_______________________________________

_________________

_________________

APPROVED:

_________________

_______________________________________

_________________

_________________

FBMS INVOICE NO.:_________________
DI-382 - Page 2 of 2