Relocation Assistance Unit Record

Airport: Project: Sponsor: Parcel: County: Unit:

Residential Business Farm Nonprofit Organization

Offer Made: First Contact: File Closed:

Person Interviewed By: Interviewed: Name: Address: Telephone No.: ( )

Members of Household (if applicable) Last Name First Name SS/FEIN No. Age Sex xxx-xx- xxx-xx- xxx-xx- xxx-xx- xxx-xx- xxx-xx- xxx-xx-

Remarks: (Family composition, special needs, etc.)

RHP Eligibility Rent Amount: Housing of Last Resort: Yes No

Existing Residence Occupancy Occupancy Date: Status: Type of Own Rent Dwelling: Dwelling Value: Monthly Rent: Number of Bedrooms: Baths: Rooms: Replacement Dwelling Desired Assistance Requested? Yes No Desired Dwelling Type: Relocation Number of Bedrooms: Baths: Rooms: Special Features Price Range of to House: Maximum Monthly

Printed on 4/6/2018 Page 1 of 3 AER 2516 (Rev. 10/01/14) Replacement Business Desired Desired Relocation Area: Type of Property: Special Features Required: Replacement Property 30-Day Notice Sent: DSS Inspection Date: Date Relocated: Address: Telephone No.: ( )

Relocation Payment Record Notice of Receipt Date Type Amount Claim Date (if available)

Remarks:

Referrals No. of Rooms or Asking Price Date Address SF of Area or Rent Disposition

Parcel: Airport:

Printed 4/6/2018 Page 2 of 3 AER 2516 (Rev. 10/01/14) Narrative Log: (Date, Summary of action or activity and initials of writer for each contact with the relocatee is required) Date Summary of Action Initials

Parcel: Airport:

For information about IDOTs collection and use of confidential information review the department’s Identity Protection Policy.

Printed 4/6/2018 Page 3 of 3 AER 2516 (Rev. 10/01/14)