<p> Relocation Assistance Unit Record</p><p>Airport: Project: Sponsor: Parcel: County: Unit:</p><p>Residential Business Farm Nonprofit Organization</p><p>Offer Made: First Contact: File Closed:</p><p>Person Interviewed By: Interviewed: Name: Address: Telephone No.: ( ) </p><p>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-</p><p>Remarks: (Family composition, special needs, etc.) </p><p>RHP Eligibility Rent Amount: Housing of Last Resort: Yes No</p><p>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 </p><p>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.: ( ) </p><p>Relocation Payment Record Notice of Receipt Date Type Amount Claim Date (if available)</p><p>Remarks: </p><p>Referrals No. of Rooms or Asking Price Date Address SF of Area or Rent Disposition</p><p>Parcel: Airport: </p><p>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</p><p>Parcel: Airport: </p><p>For information about IDOTs collection and use of confidential information review the department’s Identity Protection Policy.</p><p>Printed 4/6/2018 Page 3 of 3 AER 2516 (Rev. 10/01/14)</p>