Step 1 of 4

Print or Type All Information - Read Rules on Page 2

1. Property Owner's Name:

TxC Parcel ID:

TxC ROW Project ID:

County:

ROW CSJ:

2. Name and Address of Applicant:

Telephone No.:

3. Place of Relocation (Address):

4. Occupancy of Property Acquired by State:

From (Date):

To (Date of Move):

Owner

Tenant

Business

Advertising Sign

Farm

Residential

Nonprofit

Other

5. Type Activity/Property to be Moved:

6. Value of Property to be Moved: $

7. Distance of Move:

Yards;

Miles

8. Time Required to Move:

Hours;

Day(s)

9. Amount Requested for Self-Move: $

10. Notification has been received to move from State-acquired property and authorization is requested for a self-move of all personal property from the parcel at a cost not to exceed the amount shown in Block 9. Enclosed with this request is a list of all property to be relocated together with a tabulation of items requiring special handling, disconnection and reinstallation, plus special equipment and packing materials essential for the completion of this move. I certify that all information attached hereto or included hereon is true and correct. I further certify that all property shown on the attached listing will be moved to, and installed at, the address shown in Block 3 above in accordance with the terms under which the self-move payment is authorized.

Date:

Applicant’s Signature

Title or Position (Owner, Manager, etc.)

Step 2 of 4

Spaces Below to be Completed by State

11. Controlling Dates	Mo.	Day	Yr.
a. First Offer in Negotiationshere
b. Property Acquired by State
c. Required to Move

12. Cost estimates (copies attached)

a. High Commercial Estimate $

b. Low Estimate or Dept. Cost Finding $

I have prepared and examined this request and all supporting documentation and recommend

Approval

Denial

Date

Right of Way Agent

I have examined this request and supporting documentation and:

Recommend a Payment of $

Find that payment cannot be authorised because

(List reasons payment cannot be authorized. Use extra page if necessary)

Date

Right of Way Manager

Step 3 of 4

Director Division Approval

Payment is approved in the amount of $

Date

* Right of Way Division Director

Title:

Printed Name:

*Amount exceeding $50,000 for Residential requires Right of Way Division Director approval

*Amount exceeding $500,000 for Non-Residential requires Right of Way Division Director approval

Step 4 of 4

Rules

1. Block 1 - List name of business, farm operation, nonprofit organization or person owning the personal property to be moved.

2. Block 5 - Briefly describe the activity or type of property to be moved.

3. Moving payments may include reasonable amounts for dismantling, disconnecting, packaging, loading, insuring, transportation, unloading and reinstalling personal items which are not acquired, including the reconnecting of utilities. Moving payments cannot include expenses for improvements to replacement realty.

4. Moving payments are not applicable to items classified by the Department as real property or to items retained by an owner through the owner retention process.

5. Self-move requests must include a copy of the moving plan or a list of:

a. All personal property which is to be moved from the parcel and project to the address shown in Block 3.

b. Items requiring packing and crating, removal and reinstallation and special handling. Lists indicating a need for special handling must also identify the service required plus any special equipment or technical assistance needed to move the item(s) requiring special handling.

c. All utility services needed at the replacement site to the extent that such utilities were in use by the displacee at the former location. Utility service deposits are not eligible for payment as relocation expenses.

6. The applicant herein does not have to claim payment for the negotiated self-move; he or she may still claim his or her actual cost moving expenses, but not both.

7. This request is not a claim for payment. Claims for negotiated self-moves shall be accepted only when it is determined that the displacee is eligible for such payment and that the move was completed in accordance with the specifications and requirements on which the negotiated amount is based.

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