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<br /> --~ <br /> TENANT: # IN HOUSEHOLD: <br /> ADDRESS: LIST AGES & SEX: <br /> PHONE #: MESSAGE #: <br /> <br /> <br /> ADDRESS YOU MOVED/WILL BE DISPLACED FROM: <br /> # OF BEDROOMS: I HOW LONG DID YOU LIVE THERE: I RENT: $ UTILITIES: $ <br /> ADDRESS YOU WILL OR HAVE MOVED TO: <br /> # OF BEDROOMS: I DATE MOVE WILL/DID OCCUR: I RENT: $' UTILITIES: $ <br /> REASONS FOR DISPLACEMENT (CHECK ONE) <br /> NON-RESIDENTIAL DEVELOPMENT [ ] CODE ENFORCEMENT [ ] <br /> IS DISPLACEMENT: TEMPORARY [ ] OR PERMANENT [ ] <br /> HOUSEHOLD INCOME (List for all household members over the age of 18) <br /> NAME SOURCE (Employment, AFDC, SSI, Social Security, MONTHLY <br /> Pension, etc.) INCOME <br /> <br /> <br /> <br /> Total Income $ <br />. - L --_I.... ---'-if'" ^~A ^f'f':....... nnrlt>r " .L.. .1..- -1..-.-- .~+~.......^.i^n :~ trnt> <>nrl I'nrrpl't TlwP. nroml!;ß to Inform the City 0 <br /> <br />EXHIBIT IV <br /> <br />I REWCATION CLAIM FORM: ORDINANCE # 2048 ! <br />I I <br /> <br />Redwood City of any changes in my/our status. My/our signature(s) below authorizes the City of Redwood City to make necessary inquiries <br />for the purpose of verifying the statements herein. My/our signature(s) is also a form claim for Relocation Benefits under the City's Ordinance <br />#2048. <br /> <br />(Signature) <br /> <br />(Signature) <br /> <br />(Date) <br /> <br />28 <br />