<p> PRICE DIFFERENTIAL PAYMENT (PDP) OWNER LAST RESORT HOUSING (LRH-O) (up to $22,500 -> PDP - $22,501 or more -> LRH-O)</p><p>NAME: CODE: PARCEL: REVIEWER: </p><p>Submit Previously when Attached Submitted available Form # Required Items</p><p>NA NA Voucher Original signed claim voucher + 1 copy </p><p>NA W-9 Original + 1 copy (if not previously submitted) </p><p>NA # 16 90 Day Notice signed by the agent and displacee</p><p>NA NA # 15 Replacement Housing Computation (top & middle completed)</p><p>Appraisal Relocation Breakout form, Breakdown page, and any other BO NA pertinent pages from Appraisal (owners only)</p><p>Personal photo(s) of the subject dwelling and all outbuildings Photo NA (Front view photo and adjacent property photos are required)</p><p>NA # 14 or 14T Fully completed and signed (3 comps are required if available)</p><p>NA Photo Photos of comparables </p><p>MLS and/or data sheets for each comparable listed on the R14 with Comp Data Sheets NA photos of the dwelling and outbuildings</p><p># 18 Decent, Safe, & Sanitary Inspection</p><p>Photo Photo of replacement </p><p>NA Proof of Cost Purchase Agreement, Construction Contract, BPO * Must indicate cost and be signed by all responsible parties.</p><p># 22, 22A, 23 Agreement for Advanced RHP </p><p>Copy of the replacement HUD signed by seller & buyer and new Deed HUD / Deed signed by seller, or signed and recorded Land Contract</p><p>Unused Data Additional data sheets (newspaper ads, real estate magazine ads, MLS NA Sheets data sheets, realtor property sheets) for searched comparables Must include comments for why they were not considered and dates of when they * were searched</p><p>NA NA # 8 “PARC” Agent’s Report detailing the claim * Delivery Instructions must be noted * R8 does not need to be lengthy, but it must be specific and complete * R8 must be signed by both the agent and displacee Last Resort Housing requires additional information which is listed in sections  5.8-5.9 of the Relocation Manual.</p><p>PDP / LRH-O REVISED 07/2014 NAME: CODE: PARCEL: REVIEWER: </p><p>Submit Previously when Attached Submitted available Form # Required Items</p><p>NA NA Voucher Original signed claim voucher + 1 copy </p><p>COMPLIANCE CERTIFICATION I, AGENT NAME & TITLE, AGENT COMPANY, certify that this submittal is made in good faith; that the supporting data is accurate and complete to the best of my knowledge and that this submittal is in accordance with 49 CFR Part 24, PL 91-646 and IC 32-24 and that all applicable rules and regulations of the Federal Highway Administration have been complied with.</p><p>(Signature) AGENT NAME & TITLE AGENT COMPANY Phone: AGENT PHONE Email: AGENT EMAIL Reviewer Comments: ______</p><p>Page 5</p><p>PDP / LRH-O REVISED 07/2014</p>