HUD-40055 Claim for Moving And Related Expenses Nonresidential
In the case of wanting to claim non-residential moving expenses, the following form has to be completed and submitted along with all documents that prove eligibility.
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form HUD-40055(06/20 16) Previous editions are obsolete Page 1 of 5
For Agency Name of Agency Project Name or Number Case Nu mber Use Only
OMB Approval No. 2506-0016(exp. 4/30/201 8) Claim for Actual
Reasonable
Moving and Related
Expenses -
Nonresidential U.S. Department of Housing
and Urban Development
(49 CFR 24 Subpart D)
Section A. General
Instructions: This claim form is for the use of displaced businesses, nonprofit organizations, and farms that wish to claim a payment for
Actual Reasonable Moving and Related Expenses, including Reestablishment Expenses , rather than claim a Fixed Payment, under
the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (URA). The Agency will explain the differ ence
between the two payments and will help you complete this form. HUD provides information on these requirements and other guidan ce
materials on its website at
www.hud.gov/relocation . If you are eligible for either payment, the Agency will help you to determine which is
most advantageous. If the full amount of your claim is not approved, the Agency will provide you with a written explanation of the reason. If
you are not satisfied with the Agency’s determination, you may appeal the determination. The Agency will explain how to make an appeal.
All claims for payments must be filed no later than 18 months from the date of displacement (see 24.207(d)).
Attach supplemental pages as necessary. All expenses must be thoroughly identified and be accompanied by receipts or other
appropriate documentation to be eligible for payment. Professional services and other claims for time expended based on salaries,
earnings or fees related to 49 CFR 24.301(g)(12), 24.301(g)(17)(iii)-(vi), and 24.303(b), must be actual, reasonable, necessary, and should
be preapproved by the Agency.
( Eligible Moving Expenses: See 24.301(g)(1)-(7); 24.301(g)(11)-(18) & 24.303; Ineligible Moving Expenses: See 24.301(h))
( Eligible Reestablishment Expenses: See 24.304(a); Ineligible Reestablishment Expenses: See 24.304(b))
Nonprofit Organization Partnership Nonprofit Organization No (If “No," attach an explanation)
1. Name of Business, Farm or Nonprofit Organization 2. Name, Title, Address and Telephone Number of Claimant or Claimant's
Authorized Agent
3. Address from which Business, Farm or Nonprofit Organization moved
4a. Address to which Business, Farm or Nonprofit Organization moved
5. Type of Operation (Check One) 6. Type of Ownership (Check One) 7. Is this a Final Claim?
Business Farm Operation Sole Proprietorship Corporation Yes
4b. Date Move Started 4c. Date Move Completed
(mm/dd/yyyy) (mm/dd/yyyy)
8. Certification of Legal Residency in the United States (Please read instructions below before completing this section.)
Instructions: To qualify for relocation advisory services or relocation payments authorized by the Uniform Relocation Assistance and Real Pro perty
Acquisition Policies Act, a “displaced person” must be a United States citizen or national, or an alien lawfully present in the United States. The certification
below must be completed in order to receive any relocation benefits. (This certification may not have any standing with regard to applicable State
laws providing relocation benefits.) Please address only the category that describes your citizenship status. For item (2), please fill in the correct number
of partners. The certification for a nonresidential displaced person may be signed by an owner or other person authorized to sign on its behalf.
Your signature on this claim form constitutes certification. See 49 CFR 24.208(g) & (h) for hardship exceptions.
NONRESIDENTIAL DISPLACEMENTS
(1) Sole Proprietorship. (2) Partnership. (3) Corporation. (Name of Corporation)
I certify that I am: (check one) I certify that there are ______ partners in the I certify that _____ ______________________,
_____ a citizen or national of the United States partnership and that______ are citizens or is established pursuant t o State law and is
_____ an alien lawfully present in the United States. nationals of the United States and _____ are authorized to conduct business in the aliens lawfully present in the United States. United States.
) R U P K D V E H H Q U H Y L V H G 6 H H O D V W S D J H \f
form HUD-40055
( 06/20 16) Previous editions are obsolete Page 2 of 5
Section B. Supporting Data for Moving Expenses (Not identified in Sections C, D, E, F or G) (49 CFR 24.301(d) & 24.301(e)) (Attach supplemental page
if additional space is needed and attached receipts for costs incurred.) (Identify if move is commerical move , self move , or combination move ;
if combination move, identify each expense as commerical or self move.)
(1) $ $
(2)
(3)
(4)
(5) Total Costs (Include this amount in line (1) of Item 9, Total) $ $
Expense Identification
Amount Claimed For Agency Use Only
Section C. Supporting Data for Storage Costs (49 CFR 24. 301(g)(4)) Name and Address of Storage Company
Computation of Storage Costs
Item Amount For Agency Use Only
Monthly Rate for Storage $ $
Number of Months in Storage
Total Storage Costs (Include this amount in line (1) of Item 9, Total) $ $
Description of Property Stored (List may be attached)
Is This a Final Claim for Storage?
Yes No
Date Moved to Storage Date Moved From Storage
(mm/dd/yyyy) (mm/dd/yyyy)
(1) Searching Time Number of Hours ( ) x Hourly Rate of Earnings ( ) = $ $
(2) Time Spent Obtaining Permits, Attending Zoning Hearings
Number of Hours ( ) x Hourly Rate of Earnings ( ) = $ $
(3) Time Spent Negotiating Purchase/Lease of Replacement Site
Number of Hours ( ) x Hourly Rate of Earnings ( ) = $ $
(4) Transportation (Consult with Agency on allowable rate per mile of personal vehicle) $ $
(5) Lodging (Dates: Attach receipts) $ $
(6) Fees Paid to Real Estate Broker or Agent, (Excluding fees or commissions related to site purchase)
(Attach contract or other evidence) $ $
(7) Cost of Meals $ $
(8) Other Expenses (Specify and attach receipts) $ $
(9) Total Searching Expenses
(Add lines (1) thru (9). Include this amount, or $2,500, whichever is less, in line (1) of Item 9 Total.) $ $
Section D. Supporting Data for Searching Expenses
(49 CFR 24.301(g)(17))
Amount Claimed For Agency Use Only
Section E. Supporting Data for Payment for Actual Direct Loss of Personal Property (List separately each item for which amount claimed in Column
(f) is more than $500. Other Items may be grouped together. The Agency will advise on acceptable method for listing items. Attach additional
sheets, as needed.) (49 CFR 24.301(g)(14))
(a) (b) (c) (d) (e) (f) (g)
Identify Personal Property Fair Market Value As Is Proceeds From Value Not Recovered Estimated Cost of Amount Claimed For Agency
for Which Payment for For Continued Use At Sale By Sale Moving Ol d Property (Lesser of Use Only
Actual Direct Loss is Present Location (Column (b) minus As Is (To be entered Column (d) or
Requested (Attach appraisals Column (c)) by Agency) (e))
or other evidence) (see 24.301(g) (14)(ii))
$ $ $ $ $ $
(1) Total (Add all entries in column (f) above) $ $
(2) Cost of Effort to Sell Property (e.g., advertising) $ $
(49 CFR 24.301(g)(15))
(3) Total Amount Claimed (Add lines (1) and (2). $ $
Include this amount in line (1) of Item 9 Total)
Claimant's Release of Personal Property
I/We release to the Agency ownership of all personal property
remaining on the real property.
Signature(s) of Claimant(s) or Agent Date (mm/dd/yyyy)
form HUD-40055
( 06/20 16) Previous editions are obsolete Page 3 of 5
Identify Substitute Actual Cost of Proceeds From Net Cost of Es timated Cost of Amount Claimed For Agency Personal Property Substitute Property Sale orTrade-in of Substitute Moving and Reinstalling (Lesser of Use Only for which Payment Delivered and Installed Property That Was Personal Property Replaced Item (To be column (d) is Requested at New Location Replaced (Column (b) minus entered by agency) or (e)) (Attach documentation) Column (c)) (see 24.301(g)(16)(ii))
Section F. Supporting Data for Substitute Personal Property. List separately each item for which amount claimed in column (f) is more than $500. Other items may be grouped together. The agency will advise on acceptable method of listing items. Attach additional sheets, as needed.) (49 CFR 24.301(g)(16))
(a) (b) (c) (d) (e) (f) (g)
$ $ $ $ $ $
(1) Total (Add all entries in column (f) above) $ $
(2) Cost of Effort to Sell Property (e.g., advertising)
(49 CFR 24.301(g)(15)) $ $
(3) Total Amount Claimed (Add lines (1) and (2). $ $ Include this amount in line (1) of Item 9 Total)
Claimant's Release Of Personal Property
I/We release to the Agency ownership of all personal
property remaining on the real property.
Signature(s) of Claimant(s) or Agent Date (mm/dd/yyyy)
Section G. Supporting Data for Related Nonresidential Expenses (49 CFR 24.303)
Only if applicable and Determined Actual, Reasonable and Necessary. (Attach supplemental page, if needed)
Amount For Agency
Expense Identification Claimed Use Only
(1) Utility Connections from Right-of-Way to Improvements at Replacement Site.
(2) Professional Services for Site Suitability Determination
(Based on Agency pre-approved reasonable hourly rates) Number of Hours ( ) X Hourly Rate of Earnings ($ ) =
(3) Impact Fees or One Time Assessments for Utility Usage.
Total Related Nonresidential Expenses: (Add lines (1) through (3))
(Include this amount in line (1) of Item 9 Total)
(1)
$ $
(2)
(3)
(4)
(5) Total Costs (Enter this amount, or $ 25, 000, whichever is less, on line (2) of Item 9) $ $
Section H. Supporting Data for Reestablishment Expenses. (49 CFR 24.304) (Attach supplemental page if additional space is needed.) Amount For Agency Expense Identification Claimed Use Only
form HUD-40055
( 06/20 16) Previous editions are obsolete Page 4 of 5
Section I. Certification By Claimant(s): I certify that the information on this claim form and supporting documentation is true and complete and that I have not been paid for these expenses by any other source. Signature(s) of Claimant(s) or Claimant's Authorized Agent Title (Type or Print) Date
X
To Be Completed by Agency
Payment Action Amount of Payment Signature Name (Type or Print) Date (mm/dd/yyyy)
10. Recommended $
11. Approved $
W arning:
HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
(1) Moving Expenses (From Section B, C, D, E, F, G) $ $
(2) Reestablishment Expenses (From Section H) $ $
(3) Other (Attach explanation) $ $
(4) Total Amount Claimed (Add lines (1) thru (3)) $ $
(5) Amount Previously Received, if any $ $
(6) Amount Requested (Subtract line (5) from line (4)) $ $
9. Computation of Payment
Item Amount For Agency Use Only
Remarks:
Public reporting burden for this collection of information is estimated to average 1.5 hours per response. This includes the time for collecting, revi ewing, and reporting the data. The information is being collected under the authority of the Uniform Relocation Assistance and Real P roperty Acquisition Policies Act of 1970, and implementing regulations at 49 CFR Part 24 and will be used for determining whether you are eligible to receiv e a payment for moving and related expenses and the amount of any payment. Response to this request for information is required in order to receive the benefits to be derived. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OM B control number.
(NOTE: Updated to incorporate MAP21 statutory changes to the URA effective on 10/01/2014. Please note the current URA
regulations of 49 CFR part 24 will be revised in a future URA rule making to reflect MAP21 changes. For additional information
on MAP21changes to the URA for HUD programs and projects, refer to HUD Notice CPD 1409 at the following website:
http://portal.hud.gov/hudportal/documents/huddoc?id=1409cpdn.pdf . \f
Page 5 of 5 form HUD-40055
( /201 )
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