Displacee Information

Displacee’s Name:

ROW CSJ:

Parcel No:

Displacement Address:

Own

Rent

Square Footage:

Lease Amount: $

Replacement Address:

Special moving equipment needed:

Pallet Jack

Crane

Forklift

Flatbed

Other

Distance of move:

Date move to begin:

Time needed for move:

Storage required:

Special utility requirements for replacement site:

Displacement Requirements

Hazardous or Regulated materials to be moved:

Zoning considerations:

Regulatory issues:

Permits needed:

Contractors needed:

Electrician

Plumber

Equipment Technician

Security System Technician

Other

Date of personal property inventory (attached):

Date of merchandise for resale inventory (attached):

Other special requirements (attach additional sheets if necessary):

Displacee's Acknowledgment

Displacee's Signature:

Displacee's Name (printed):

Displacee's Title/Position:

Relocation Agent's Signature:

The Texas Department of Transportation maintains the information collected through this form. With few exceptions, you are entitled on request to be informed about the information that we collect about you. Under Sections 552.021 and 552.023 of the Government Code, you also are entitled to receive and review this information. Under Section 559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect.

*RMP*