Non-residential by HC120704084543

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									RE-600-1                                           STATE OF OHIO                                           County
11/16/2009                            DEPARTMENT OF TRANSPORTATION                                         Route
                                                                                                           Section
                                               RELOCATION ASSISTANCE                                       Parcel No.
                                     BUSINESS OCCUPANT INTERVIEW FORM                                      PID No.


                                                   Owner or Tenant?

Type of Operation:
Name of Property Owners:
Name of Site Occupant:
Occupancy Date:
Address of Location:                                       Contact Information:
                                                           Office Phone:
                                                           Cell Phone:
                                                           Email Address:
Address (if different than subject location):
                                                                             Annual Net Profit: $                       -



Authorized Representative present for interview:
Title of Authorized Representative:
Name of Interviewing Agent:
Pre-Acquisition Interview Date:

Is this the only location of this business?:                        Is this part of a chain?:

Briefly describe the operation to be moved:




What lease terms or contractual obligations is the company presently under?:
Expiration Date of Lease or Contract:
Terms:
Does your company currently enjoy specific site needs that will need to be available at the replacement
site? Do you anticipate difficulty in locating such a site?:

         Briefly Explain:



Will your company need specialized assistance to move machinery or personal property beyond those
services typically provided for by a mover?

Can these services be provided by your current staff?:

Is there a specific time of year that the move could take place that would least effect your operation?:

             Winter         Spring       Summer     Fall


How much time will be needed to complete the move once it has begun?:

Relocaton Assistance Accepted or Declined?:


Inteviewer's Signature:                                                           Date:
RE-610-1                                              STATE OF OHIO                                                        County            0
11/16/2009                                     DEPARTMENT OF TRANSPORTATION                                                Route             0
                                                                                                                           Section          0.000
                                            SITE OCCUPANT RELOCATION RECORD                                                Parcel No.        0
                                             (Business, Farm & Non-Profit Organization)                                    PID No.           0


Type of Operation on site:                          0
Name of Property Owners:                            0
Name of Site Occupant:                              0
Is the Occupant and owner or tenant of the site?:                                                     0
Address of subject property:                                                   Contact Information:
                                 0                                             Office Phone:                 0
                                 0                                             Cell Phone:                   0
                                                                               Email Address:                0
Name of Interviewee:                                0                                          Pre-Acq. Survey Date:       1/0/1900
Name of Interviewer:                                0


Relocation assistance:                              0


Breif description of Operation:
0




Occupancy Date:                                         1/0/00                 Move Authorization Date:
Notice of Eligibility Date:                                                    Date of Move:
Date of Initiaion of Negot. (ION):                                             Post Move Inspection Date:
90 Day Notice Expiration Date:                                                 Post Move Performed By:
Date signed:                                                                   Possession Date:
Service of Summons:                                                            Final Date to File a Claim:
                                                                               Property Management Notified:
Vacate Notice:                                      Delivered:                 Expires:

Move Cost Basis:                                    0
Other Moving Expenses:                                                         App.Date:                         Amount:
                                                                               App.Date:                         Amount:
                                                                               App.Date:                         Amount:
                                                                               App.Date:                         Amount:

      Relocated:      With RA Assistance                  W/O RA Assistance                         Occupancy Status at Replacement Site:


Replacement site Address:                                                      Replacement Contact Information:
                                                                 0             Office Phone:
                                                                 0             Cell Phone:

                                                                               Email Address:
                                                                         Appeal Data
Meeting Date:                                           Denied       Granted


                              Basis for Granting:
RE-610-C            STATE OF OHIO                         County           0
11/16/2009   DEPARTMENT OF TRANSPORTATION                 Route           0
                                                          Section        0.00
                      CLAIM RECORD                        Parcel No.      0
                                                          PID No.         0
                                       Date                  Date
Claim Type    Payee        Amount    Approved Date Signed Submitted Date Delivered
RE-613-1                                              STATE OF OHIO                                                          County:          0
11/16/2009                                     DEPARTMENT OF TRANSPORTATION                                                  Route:           0
                                              INVENTORY OF PERSONAL PROPERTY                                                 Section:        0.000
                                                                                                                             Parcel No:       0
                                     BUSINESS, FARM OR NON-PROFIT ORGANIZATION                                               PID No:          0


Name of Displaced Person:                 0
Type of Relocation:      0
Move Cost Basis:                                         Move #2:                                      Move #3:
              (Layout of floor plan detailing location of machinery, equipment, etc. may be useful as well as photographs of personal
              property to be moved. Buildings and/or rooms should be identified individually with the personal property contained therein
              so noted.)




              Address of Subject:                                       Replacement Address:
              0
              0

                            (I hereby certify the items herein noted (and attached hereto) to be the only items of personal property which
                            the State is liable for relocating)


              Signature of Relocated Person:                                                                                 Date:

              Signature of Agent:                                                                                            Date:
RE-617-1                                                    STATE OF OHIO                                                                      County:              0
 11/16/2009                                         DEPARTMENT OF TRANSPORATION                                                                Route:               0
                                                   RELOCATION ASSISTANCE PROGRAM                                                               Section:            0.000
                                                     NON-RESIDENTIAL CLAIM FORM                                                                Parcel No:           0
                                                                                                                                               PID No:              0


Full Name of Claimant:             0


Address Moved From:                0                                       Address Moved To:                    0
                                   0                                                                            0


                                WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                                    MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                Type of Move:

                If Fixed Payment:                            1st year net income:                                       2nd year net income:


                                                                                                            MOVE AMOUNT CLAIMED: $                           -
                Additional Payments:
                Search ($2,500.00 Max)                                                                                                         $             -
                Remainng Life / Licenses & Permits                                                                                             $             -
                Obsolete Relettering Signs and Stationary                                                                                      $             -
                Storage Costs                                                                                                                  $             -
                Acutal Direct Loss of Tangible                                                                                                 $             -
                Substitute Equipment                                                                                                           $             -
                Other                                                                                                                          $             -
                Other                                                                                                                          $             -



                                                                                     ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                   -
                Related Expenses:
                Utilities from the R/W to Improvements                                                                                         $             -
                Professional Feasibility Studies                                                                                               $             -
                Impact Fees or One Time Assessments                                                                                            $             -


                                                                                          RELATED EXPENSES AMOUNT CLAIMED: $                                 -
RE-ESTABLISHMENT ($10,000.00 MAX)
                Repairs or Improvements Required by Code                                                                                       $             -
                Modifications to Accommodate the Business                                                                                      $             -
                Exterior Signage to Advertise the Business                                                                                     $             -
                Replacement of Warn Surfaces                                                                                                   $             -
                Advertisement of Location                                                                                                      $             -
                Increased Cost of Operation / 2 years                                                                                          $             -


                                                                                              RE-ESTABLISHED AMOUNT CLAIMED: $                               -


                                                                                             AMOUNT BEING CLAIMED THIS DATE: $                               -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project, that such amounts
are true and correct and supported by documentation furnished to the Department of Transportation as required under the rules of the Department. Further, as
the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit organization, is presnet in the United States unlawfully,
and if incoroporated, we are authorized to do business in the United States.


                           Date:                                                                   Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the Director, Ohio
Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is entitled to the amount indicated
above.

                           Date:                                                                   Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved for signing by
the displaced person.


Reviewer Signature:                                                        Title:                                                              Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                      Name:
                   Address:
        City, State and Zip:
RE-617-1                                           STATE OF OHIO                                                               County:                  0
11/16/2009                                 DEPARTMENT OF TRANSPORATION                                                         Route:                   0
                                          RELOCATION ASSISTANCE PROGRAM                                                        Section:                0.000
                                            NON-RESIDENTIAL CLAIM FORM                                                         Parcel No:               0
                                                                                                                               PID No:                  0


Full Name of Claimant:              0


Address Moved From:                 0                                       Address Moved To:
                                    0


                          WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                              MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:           1st year net income:                                      2nd year net income:


                                                                                            MOVE AMOUNT CLAIMED: $                               -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                       $                 -
                  Remainng Life / Licenses & Permits                                                                           $                 -
                  Obsolete Relettering Signs and Stationary                                                                    $                 -
                  Storage Costs                                                                                                $                 -
                  Acutal Direct Loss of Tangible                                                                               $                 -
                  Substitute Equipment                                                                                         $                 -
                  Other                                                                                                        $                 -
                  Other                                                                                                        $                 -



                                                                        ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                    -

                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                       $                 -
                  Professional Feasibility Studies                                                                             $                 -
                  Impact Fees or One Time Assessments                                                                          $                 -


                                                                           RELATED EXPENSES AMOUNT CLAIMED: $                                    -

RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                     $                 -
                  Modifications to Accommodate the Business                                                                    $                 -
                  Exterior Signage to Advertise the Business                                                                   $                 -
                  Replacement of Warn Surfaces                                                                                 $                 -
                  Advertisement of Location                                                                                    $                 -
                  Increased Cost of Operation / 2 years                                                                        $                 -


                                                                             RE-ESTABLISHED AMOUNT CLAIMED: $                                    -


                                                                                           TOTAL AMOUNT CLAIMED: $                               -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project, that
such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the rules of the
Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit organization, is
presnet in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                       Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is entitled
to the amount indicated above.

                            Date:                                                       Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved for
signing by the displaced person.


Reviewer Signature:                                            Title:                                          Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-617-1                                            STATE OF OHIO                                                                 County:                 0
11/16/2009                                  DEPARTMENT OF TRANSPORATION                                                           Route:                  0
                                           RELOCATION ASSISTANCE PROGRAM                                                          Section:               0.000
                                             NON-RESIDENTIAL CLAIM FORM                                                           Parcel No:              0
                                                                                                                                  PID No:                 0


Full Name of Claimant:              0


Address Moved From:                 0                                         Address Moved To:
                                    0


                          WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                              MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:              1st year net income:                                      2nd year net income:


                                                                                              MOVE AMOUNT CLAIMED: $                               -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                          $                -
                  Remainng Life / Licenses & Permits                                                                              $                -
                  Obsolete Relettering Signs and Stationary                                                                       $                -
                  Storage Costs                                                                                                   $                -
                  Acutal Direct Loss of Tangible                                                                                  $                -
                  Substitute Equipment                                                                                            $                -
                  Other                                                                                                           $                -
                  Other                                                                                                           $                -



                                                                        ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                      -

                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                          $                -
                  Professional Feasibility Studies                                                                                $                -
                  Impact Fees or One Time Assessments                                                                             $                -


                                                                            RELATED EXPENSES AMOUNT CLAIMED: $                                     -

RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                        $                -
                  Modifications to Accommodate the Business                                                                       $                -
                  Exterior Signage to Advertise the Business                                                                      $                -
                  Replacement of Warn Surfaces                                                                                    $                -
                  Advertisement of Location                                                                                       $                -
                  Increased Cost of Operation / 2 years                                                                           $                -


                                                                                RE-ESTABLISHED AMOUNT CLAIMED: $                                   -


                                                                                             TOTAL AMOUNT CLAIMED: $                               -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project, that
such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the rules of the
Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit organization, is presnet
in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                         Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is entitled to
the amount indicated above.

                            Date:                                                         Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved for
signing by the displaced person.


Reviewer Signature:                                               Title:                                          Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-617-1                                           STATE OF OHIO                                                               County:                  0
11/16/2009                                 DEPARTMENT OF TRANSPORATION                                                         Route:                   0
                                          RELOCATION ASSISTANCE PROGRAM                                                        Section:                0.000
                                            NON-RESIDENTIAL CLAIM FORM                                                         Parcel No:               0
                                                                                                                               PID No:                  0


Full Name of Claimant:              0


Address Moved From:                 0                                       Address Moved To:
                                    0


                          WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                              MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:           1st year net income:                                      2nd year net income:


                                                                                            MOVE AMOUNT CLAIMED: $                               -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                        $                -
                  Remainng Life / Licenses & Permits                                                                            $                -
                  Obsolete Relettering Signs and Stationary                                                                     $                -
                  Storage Costs                                                                                                 $                -
                  Acutal Direct Loss of Tangible                                                                                $                -
                  Substitute Equipment                                                                                          $                -
                  Other                                                                                                         $                -
                  Other                                                                                                         $                -



                                                                        ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                    -
                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                        $                -
                  Professional Feasibility Studies                                                                              $                -
                  Impact Fees or One Time Assessments                                                                           $                -


                                                                           RELATED EXPENSES AMOUNT CLAIMED: $                                    -
RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                      $                -
                  Modifications to Accommodate the Business                                                                     $                -
                  Exterior Signage to Advertise the Business                                                                    $                -
                  Replacement of Warn Surfaces                                                                                  $                -
                  Advertisement of Location                                                                                     $                -
                  Increased Cost of Operation / 2 years                                                                         $                -


                                                                              RE-ESTABLISHED AMOUNT CLAIMED: $                                   -


                                                                                           TOTAL AMOUNT CLAIMED: $                               -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project, that
such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the rules of the
Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit organization, is
presnet in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                       Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is entitled to
the amount indicated above.

                            Date:                                                       Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved for
signing by the displaced person.


Reviewer Signature:                                            Title:                                          Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-617-1                                          STATE OF OHIO                                                             County:                 0
11/16/2009                                DEPARTMENT OF TRANSPORATION                                                       Route:                  0
                                         RELOCATION ASSISTANCE PROGRAM                                                      Section:               0.000
                                           NON-RESIDENTIAL CLAIM FORM                                                       Parcel No:              0
                                                                                                                            PID No:                 0


Full Name of Claimant:              0


Address Moved From:                 0                                   Address Moved To:
                                    0


                          WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                              MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:           1st year net income:                                   2nd year net income:


                                                                                         MOVE AMOUNT CLAIMED: $                              -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                    $                -
                  Remainng Life / Licenses & Permits                                                                        $                -
                  Obsolete Relettering Signs and Stationary                                                                 $                -
                  Storage Costs                                                                                             $                -
                  Acutal Direct Loss of Tangible                                                                            $                -
                  Substitute Equipment                                                                                      $                -
                  Other                                                                                                     $                -
                  Other                                                                                                     $                -



                                                                   ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                     -

                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                    $                -
                  Professional Feasibility Studies                                                                          $                -
                  Impact Fees or One Time Assessments                                                                       $                -


                                                                       RELATED EXPENSES AMOUNT CLAIMED: $                                    -

RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                  $                -
                  Modifications to Accommodate the Business                                                                 $                -
                  Exterior Signage to Advertise the Business                                                                $                -
                  Replacement of Warn Surfaces                                                                              $                -
                  Advertisement of Location                                                                                 $                -
                  Increased Cost of Operation / 2 years                                                                     $                -


                                                                          RE-ESTABLISHED AMOUNT CLAIMED: $                                   -


                                                                                        TOTAL AMOUNT CLAIMED: $                              -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project,
that such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the
rules of the Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit
organization, is presnet in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                   Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is
entitled to the amount indicated above.

                            Date:                                                   Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved
for signing by the displaced person.


Reviewer Signature:                                           Title:                                        Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-617-1                                          STATE OF OHIO                                                             County:                 0
11/16/2009                                DEPARTMENT OF TRANSPORATION                                                       Route:                  0
                                         RELOCATION ASSISTANCE PROGRAM                                                      Section:               0.000
                                           NON-RESIDENTIAL CLAIM FORM                                                       Parcel No:              0
                                                                                                                            PID No:                 0


Full Name of Claimant:              0


Address Moved From:                 0                                   Address Moved To:
                                    0


                       WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                           MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:           1st year net income:                                   2nd year net income:


                                                                                        MOVE AMOUNT CLAIMED: $                               -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                    $                -
                  Remainng Life / Licenses & Permits                                                                        $                -
                  Obsolete Relettering Signs and Stationary                                                                 $                -
                  Storage Costs                                                                                             $                -
                  Acutal Direct Loss of Tangible                                                                            $                -
                  Substitute Equipment                                                                                      $                -
                  Other                                                                                                     $                -
                  Other                                                                                                     $                -



                                                                   ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                     -

                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                    $                -
                  Professional Feasibility Studies                                                                          $                -
                  Impact Fees or One Time Assessments                                                                       $                -


                                                                       RELATED EXPENSES AMOUNT CLAIMED: $                                    -

RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                  $                -
                  Modifications to Accommodate the Business                                                                 $                -
                  Exterior Signage to Advertise the Business                                                                $                -
                  Replacement of Warn Surfaces                                                                              $                -
                  Advertisement of Location                                                                                 $                -
                  Increased Cost of Operation / 2 years                                                                     $                -


                                                                          RE-ESTABLISHED AMOUNT CLAIMED: $                                   -


                                                                                       TOTAL AMOUNT CLAIMED: $                               -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project,
that such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the
rules of the Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit
organization, is presnet in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                   Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is
entitled to the amount indicated above.

                            Date:                                                   Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved
for signing by the displaced person.


Reviewer Signature:                                           Title:                                        Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-617-1                                          STATE OF OHIO                                                              County:                   0
11/16/2009                                DEPARTMENT OF TRANSPORATION                                                        Route:                    0
                                         RELOCATION ASSISTANCE PROGRAM                                                       Section:                 0.000
                                           NON-RESIDENTIAL CLAIM FORM                                                        Parcel No:                0
                                                                                                                             PID No:                   0


Full Name of Claimant:              0


Address Moved From:                 0                                      Address Moved To:
                                    0


                          WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                              MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:           1st year net income:                                    2nd year net income:


                                                                                          MOVE AMOUNT CLAIMED: $                               -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                      $                -
                  Remainng Life / Licenses & Permits                                                                          $                -
                  Obsolete Relettering Signs and Stationary                                                                   $                -
                  Storage Costs                                                                                               $                -
                  Acutal Direct Loss of Tangible                                                                              $                -
                  Substitute Equipment                                                                                        $                -
                  Other                                                                                                       $                -
                  Other                                                                                                       $                -



                                                                       ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                   -

                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                      $                -
                  Professional Feasibility Studies                                                                            $                -
                  Impact Fees or One Time Assessments                                                                         $                -


                                                                          RELATED EXPENSES AMOUNT CLAIMED: $                                   -

RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                    $                -
                  Modifications to Accommodate the Business                                                                   $                -
                  Exterior Signage to Advertise the Business                                                                  $                -
                  Replacement of Warn Surfaces                                                                                $                -
                  Advertisement of Location                                                                                   $                -
                  Increased Cost of Operation / 2 years                                                                       $                -


                                                                            RE-ESTABLISHED AMOUNT CLAIMED: $                                   -


                                                                                         TOTAL AMOUNT CLAIMED: $                               -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project, that
such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the rules of
the Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit organization, is
presnet in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                     Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is entitled
to the amount indicated above.

                            Date:                                                     Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved
for signing by the displaced person.


Reviewer Signature:                                           Title:                                         Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-617-1                                          STATE OF OHIO                                                              County:                  0
11/16/2009                                DEPARTMENT OF TRANSPORATION                                                        Route:                   0
                                         RELOCATION ASSISTANCE PROGRAM                                                       Section:                0.000
                                           NON-RESIDENTIAL CLAIM FORM                                                        Parcel No:               0
                                                                                                                             PID No:                  0


Full Name of Claimant:              0


Address Moved From:                 0                                      Address Moved To:
                                    0


                          WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                              MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:           1st year net income:                                    2nd year net income:


                                                                                         MOVE AMOUNT CLAIMED: $                               -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                     $                -
                  Remainng Life / Licenses & Permits                                                                         $                -
                  Obsolete Relettering Signs and Stationary                                                                  $                -
                  Storage Costs                                                                                              $                -
                  Acutal Direct Loss of Tangible                                                                             $                -
                  Substitute Equipment                                                                                       $                -
                  Other                                                                                                      $                -
                  Other                                                                                                      $                -



                                                                       ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                  -

                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                     $                -
                  Professional Feasibility Studies                                                                           $                -
                  Impact Fees or One Time Assessments                                                                        $                -


                                                                          RELATED EXPENSES AMOUNT CLAIMED: $                                  -

RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                   $                -
                  Modifications to Accommodate the Business                                                                  $                -
                  Exterior Signage to Advertise the Business                                                                 $                -
                  Replacement of Warn Surfaces                                                                               $                -
                  Advertisement of Location                                                                                  $                -
                  Increased Cost of Operation / 2 years                                                                      $                -


                                                                            RE-ESTABLISHED AMOUNT CLAIMED: $                                  -


                                                                                        TOTAL AMOUNT CLAIMED: $                               -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project,
that such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the rules
of the Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit organization,
is presnet in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                    Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is entitled
to the amount indicated above.

                            Date:                                                    Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved
for signing by the displaced person.


Reviewer Signature:                                           Title:                                         Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-617-1                                          STATE OF OHIO                                                             County:                 0
11/16/2009                                DEPARTMENT OF TRANSPORATION                                                       Route:                  0
                                         RELOCATION ASSISTANCE PROGRAM                                                      Section:               0.000
                                           NON-RESIDENTIAL CLAIM FORM                                                       Parcel No:              0
                                                                                                                            PID No:                 0


Full Name of Claimant:              0


Address Moved From:                 0                                   Address Moved To:
                                    0


                          WARNING - FALSE, FICTICIOUS OR FRAUDULENT STATEMENTS
                              MAY LEAD TO IMPRISONMENT OR FINES, OR BOTH

TYPE OF DISPLACEMENT:



                  Type of Move:

                  If Fixed Payment:           1st year net income:                                   2nd year net income:


                                                                                         MOVE AMOUNT CLAIMED: $                              -

                  Additional Payments:
                  Search ($2,500.00 Max)                                                                                    $                -
                  Remainng Life / Licenses & Permits                                                                        $                -
                  Obsolete Relettering Signs and Stationary                                                                 $                -
                  Storage Costs                                                                                             $                -
                  Acutal Direct Loss of Tangible                                                                            $                -
                  Substitute Equipment                                                                                      $                -
                  Other                                                                                                     $                -
                  Other                                                                                                     $                -



                                                                   ADDITIONAL PAYMENTS AMOUNT CLAIMED: $                                     -

                  Related Expenses:
                  Utilities from the R/W to Improvements                                                                    $                -
                  Professional Feasibility Studies                                                                          $                -
                  Impact Fees or One Time Assessments                                                                       $                -


                                                                       RELATED EXPENSES AMOUNT CLAIMED: $                                    -

RE-ESTABLISHMENT ($10,000.00 MAX)
                  Repairs or Improvements Required by Code                                                                  $                -
                  Modifications to Accommodate the Business                                                                 $                -
                  Exterior Signage to Advertise the Business                                                                $                -
                  Replacement of Warn Surfaces                                                                              $                -
                  Advertisement of Location                                                                                 $                -
                  Increased Cost of Operation / 2 years                                                                     $                -


                                                                          RE-ESTABLISHED AMOUNT CLAIMED: $                                   -


                                                                                        TOTAL AMOUNT CLAIMED: $                              -

The undersigned certifies that the amounts claimed herein represent actual costs incurred in the moving of personal property from the project,
that such amounts are true and correct and supported by documentation furnished to the Department of Transportation as required under the
rules of the Department. Further, as the Owner, Manager or Operating Officer, I certify that no owner of this business, farm or non-profit
organization, is presnet in the United States unlawfully, and if incoroporated, we are authorized to do business in the United States.


                            Date:                                                   Signature:

I hereby certify that the above named claimant is an eligible displaced person in accordance with the Rules and Regulations established by the
Director, Ohio Department of Transportation, for the Adminstration of the Relocation Assistance Program and that the named claimant is
entitled to the amount indicated above.

                            Date:                                                   Signature:

I certify that I have reviewed the file material and find that the amount(s) noted above is/are adequately supported. The claim form is approved
for signing by the displaced person.


Reviewer Signature:                                           Title:                                        Date:

                                              THIS IS THE FINAL PAYMENT OF THIS FILE

Payment indicated above to be assigned to:
                       Name:
                    Address:
         City, State and Zip:
RE-618                                                              STATE OF OHIO                                                         County:       0
11/16/2009                                                   DEPARTMENT OF TRANSPORTATION                                                 Route:        0
                                                               SEARCHING EXPENSE REPORT                                                   Section:     0.000
                                                                                                                                          Parcel No:    0
                                                                                                                                          PID No:       0
Occupants Name:            0
Site Address:              0
City, State & Zip:         0
                                                                                          Transportation Cost
                                                                         Search Time                              Room     Meals
   Date              Address Viewed          Person Contacted        Hrs. Rate     Amt.   Miles Rate    Amt.     Amount   Amount     Daily Total




                                                                                                                            Total:
I certify that the statements and costs showin hereon are true and correct.


                                            Signature of Authorized Representative:                             Date:
RE 619-1                                                    State of Ohio                                              County:              0
11/16/2009                                           Department of Transportation                                      Route:               0
                                                       Loss of Goodwill Claim                                          Section:             0
                                                                                                                       Parcel No:           0
                                                                                                                       PID No:              0

                                                    Calculation of Loss of Goodwill


              If the amount of Goodwill at the replacement site is less than the amount of Goodwill attributable
              to the business prior to the acquisition, then the difference, not to exceed $10,000, is the
              compensation for the Loss of Goodwill if the business proves that any Loss of Goodwill is caused
              by the acquisition of the property.


              Claims for Loss of Goodwill must be supported by financial documentation and related
              supplemental information including a narrative description of the business as it existed before the
              relocation and a comparison to the business operations after the relocation. This should include
              a discussion about the type and amount of clientele before and after the move.



             The amount of Goodwill attributable to the business prior to the taking:                      $                        -
                                                                                                                (Goodwill prior)
                                                                                             (MINUS)

               The amount of Goodwill attributable to the business after relocation:                       $                        -
                                                                                                                (Goodwill after)


                                                                                                  =        $                        -
                                                                                                               (Loss of Goodwill)



              The undersigned certifies that the amounts claimed herein represent actual Loss of Goodwill incurred in the Relocation
              of my business, that such amounts are true and correct and supported by attached documentation. I understand this
              claim form and attached documenation will be reviewed by a three person review pannel, and if I disagree with the
              findings of the pannel, I have the right to seek judicial relief.



              (Signature of Displaced Business Owner)                                        (Date)



                                      Amount of Goodwill Loss established by panel:               =       $                             -


              (Signature of ODOT Administrator of Real Estate)                               (Date)



              (Signature of ODOT Chief Legal Counsel)                                        (Date)



              (Signature of ODOT Deputy Director for Finance and Forecasting)                (Date)
                               Frequently Asked Questions about Loss of Goodwill

1). How does the Ohio Revised Code Define Loss of Goodwill?

   Goodwill is defined in Section 163.01(K) as:

   The calculable benefits that accure to a business as a result of its location, reputation for
   dependability, skill or quality, and any other circumstances that result in probable retention of old,
   or acquisition of, new patronage.

2). Is my business eligible for Reimbursement for Loss of Goodwill?

   The law states that to be eligible for Loss of Goodwill, the entirety of the business property must be
   acquired. This does not mean that all of the Real Estate owned by your business must be acquired.
   However, enough of the the Real Estate must be acquired to substantially impact your business
   and force your business to relocate.

3). What steps does my business need to take in order to prove that Loss of Goodwill could not
    reasonably be prevented?

   Under Ohio Law, loss of Goodwill may not be reimbursed unless the owner can prove that the loss
   cannot be reasonably prevented by relocation of the business or by taking steps and adopting
   procedures that a reasonably prudent person would take and adopt in preserving the Goodwill.

   A business should search for a replacement location which will minimize any Loss of Goodwill.
   In addition, the Relocation Agent should provide advisory services to help your business obtain and
   become established in a suitable replacement location.

   If a suitable replacement site is not available and therefore, the business is discontinued, it is
   assumed that the business would lose any Goodwill which was established at the acquired site.

4). How do I claim loss of Goodwill?

   You must file this form in order to claim reimbursement for Loss of Goodwill. In the space provided
   on page one you need to state the value of the Goodwill at the site which the agency is acquiring.
   You will also need to state the value of the Goodwill at your replacement site. If the value at the
   replacement site is less, then you would be able to claim a Loss of Goodwill if you can prove the
   loss was attributed to the relocation of your business. Ohio Law limits the reimbursement of
   Goodwill to $10,000.00.

5). If I do not agree with the agency's acquisition offer and I choose to have a jury of my peers
    determine the value of my property, how does this affect my claim for Loss of Goodwill?

   Ohio Law allows for a jury to decide the amount of your Loss of Goodwill. Therefore, if you and the
   agency can not come to an agreement for the value of the acquired real estate and the agency
   files for appropriation, you may provide evidence of the Loss of Goodwill at your appropriation
   proceeding.
 6). What documentation is needed to support my claim for Loss of Goodwill?

     Claims for Loss of Goodwill must be supported by financial information and related, supplemental
     information. The following is suggested, but not required, information to be submitted with your claim:

          *      Financial statements covering the two year period preceding the date the agency offered
                 to purchase your property.
          *      Tax returns that indicate the net profits of the business for the two taxable years prior
                 to the displacement.
          *      Actual financial statements for the six month period following the re-establishment of
                 your business.
          *      Projected financial data for the twelve month period beginning six months after the
                 re-establishment of your business.
          *      A summary of comparative financial statements that demonstrate the differences
                 between the revenue streams and cash flows especially as they relate to your business'
                 Goodwill value, that existed in the business before, and after, the business was relocated.

 7). How does ODOT review my claim?

     Your claim will be reviewed by a three person review panel. The panel consists of the ODOT
     Administrator of the Office of Real Estate, the ODOT Chief Legal Counsel and the ODOT Deputy
     Director for Finance and Forecasting.

 8). What happens if I disagree with the decision of the review pannel?

     If you disagree with the panel's decision you have the right to seek judicial relief from the courts.

 9). How long do I have to file my claim?

     All claims for a relocation payment shall be filed with the Agency no later than 18 months after:

                 A.          For tenants, the date of the relocation assistance offer.

                 B.          For owners, the date of the relocation assistance offer or the date of the
                             final payment of the acquisition of real property, whichever is later.

10). If I am a landlord, may I file claim for Loss of Goodwill?

     No, landlords are not eligible to receive reimbursment for the Loss of Goodwill. However, you will
     receive Relocation Benefits to search for a replacement site, move your personal property from the
     site, and re-establish your business.
RE 621-1                                         State of Ohio                                     County:           0
11/16/2009                                Department of Transportation                             Route:            0
                                             Economic Loss Claim                                   Section:          0
                                                                                                   Parcel No:        0
                                                                                                   PID No:           0


                                          Statement of Economic Loss


             The Maximum amount which may be claimed for Economic Loss is based on a formula
             which uses your annualized net business profit expressed as a daily rate mulitiplied by
             a time period which is related to the amount of time the owner of the Real Estate has
             to consider the Agency's acquisition offer. Your Relocation Agent will assist you to
             compute this amount.

             Your actual Economic Loss must be supported with financial documentation and related
             supplemental information. Your annual business profit must be documented by using
             your Federal Income Tax return for the year preceding the Agency's offer to purchase
             the Real Estate on which your business is located.



                       Maximum amount which may be claimed for Economic Loss: $                                 -

             Claims for Economic Loss must be supported by financial documentation and related
             supplemental information.

                                                      Amount of Economic Loss incurred: $                       -



             The undersigned certifies that the amounts claimed herein represent actual Economic Loss incurred
             in the Relocation of my business, that such amounts are true and correct and supported by attached
             documentation. I understand this claim form and attached documentation will be reviewed by a
             three person review panel, and if I disagree with the findings of the panel, I have the right to seek
             judicial relief.


             (Signature of Displaced Business Owner)                           (Date)



                                       Amount of Economic Loss established by Panel: $                          -




             (Signature of ODOT Administrator of Real Estate)                  (Date)




             (Signature of ODOT Chief of Legal Counsel)                        (Date)




             (Signature of ODOT Deputy Director for Finance and Forecasting)   (Date)
                Frequently Asked Questions about Economic Loss

1). What is Reimbursement for Economic Loss?

   The Ohio Revised Code states that an owner of a business, who is required to relocate
   the business, may recover damages for the owner's actual Economic Loss resulting
   from the taking of the property, as proven by the owner by a pre-ponderance of the
   evidence.

2). Is there a maximum amount I can claim for Economic Loss?

   Yes, according to Ohio Law the maximum amount which may be claimed for Economic
   Loss is based on a formula which uses your annualized net business profit expressed
   as a daily rate multiplied by a time period which is related to the amount of time you
   have to consider the Agency's acquisition offer.

   Dividing your previous tax year's net profit by 365 days results in the annualized net
   business profit expressed as a daily rate.

   The eligibible time period is calculated by using 365 days minus the time from the date the
   Agency provided the Notice to Acquire to the owner of the Real Estate, to the date the Agency
   deposits the value of the property with the court. The law has set the minimum time
   period at 15 days. For example, if the Agency provided a written offer to purchase your
   property on January 1st, and then files for appropriation on December 1st, the time
   period would be 365 - 334 = 31 days. Therefore the maximum you would be able to claim
   for Economic Loss would be 31 days multiplied by your annualized net business profit
   expressed as a daily rate.

   If you and the Agency agree on compensation for the Real Estate and the property is
   not appropriated, the time period used in the calculation is 15 days.

   This formula arrives at the maximum amount to be reimbursed for Economic Loss. You
   will still need to provide the Agency with financial statements and other documentation
   to provie that the relocation of your business caused you to suffer Economic Loss.

3). If my business does not report a profit, can I claim Economic Loss?

   The Ohio Revised Code states that the amount of reimbursement for Economic Loss
   cannot exceed twelve months net profit of the business on a an annualized basis.
   Therefore, if your business does not report a profit in the year prior to displacement,
   you cannot claim reimbursement for Economic Loss.

4). How do I claim Economic Loss?

   You must file this form in order to claim reimbursement for Economic Loss. On this
   form you will state the amount of your Economic Loss. You will then attach financial
   statements and other documentation to support your claim. In addition, a narrative
   description of why the relocation of your business resulted in a loss shall be included
   with the claim.
5). How does ODOT review my claim?

   Your claim will be reviewed by a three person review panel. The panel consists of the
   ODOT Adminstrator of the Office of Real Estate, the ODOT Chief Legal Counsel and the
   ODOT Deputy Director of Finance and Forecasting.

6). What happens if I disagree with the decision of the review panel?

   If you disagree with the panel's decision you have the right to appeal the Panel's decision to the
   Director and/or seek judicial relief from the courts.

7). How long do I have to file my claim?

   All claims for a relocation payment shall be filed with the Agency no later than 18 months
   after:

               A.          For tenants, the date of the relocation assistance offer

               B.          For owners, the date the relocation assistance offer is made or the
                           date of the final payment for the acquisition of the real property,
                           whichever is later.

								
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