CDOT Form 436 Moving or in Lieu Payment Claim ((Business, Farm or Nonprofit Organization) - Colorado

CDOT Form 436 or the "Moving Or In Lieu Payment Claim ((business, Farm Or Nonprofit Organization)" is a form issued by the Colorado Department of Transportation.

The form was last revised in May 1, 2017 and is available for digital filing. Download an up-to-date CDOT Form 436 in PDF-format down below or look it up on the Colorado Department of Transportation Forms website.

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Project Code:
COLORADO DEPARTMENT OF TRANSPORTATION
Parcel No:
MOVING OR IN LIEU PAYMENT CLAIM
Project No:
Location:
(Business, Farm or Nonprofit Organization)
County:
Claimant’s name:
State acquired property address or location:
Replacement property address or location:
Name of Business, Farm, or Nonprofit Organization:
Moves from a business, farm or nonprofit organization (based on one or a combination of the following methods:
1) Commercial Move (based on the lower of two bids or estimates) ............................................... $
2) Self Move (based on one or a combination of the following):
a) Lower of two bids .................................................................................................................. $
b) Supported by receipted bills for labor and equipment. Hourly rates should not exceed
those paid by commercial movers for labor and equipment rental........................................ $
Eligible Actual Moving Expenses for a Business, Farm, or Nonprofit Organization:
Searching for a replacement location (not to exceed $2,500) ......................................................... $
Storage of the personal property for a period not to exceed 12 months ........................................... $
$
$
$
$
$
Related Nonresidential Eligible Expenses:
Connection to available nearby utilities from the right of way to improvements at the
replacement site. ............................................................................................................................... $
Professional Services performed prior to the purchase or lease of a replacement site. .................. $
Impact fees or one time assessments for anticipated heavy utility usage. ....................................... $
Reestablishment expenses – Nonresidential Moves (not to exceed $10,000) ................................. $
Fixed Payment for Moving Expenses – Nonresidential Moves (Not less than $1,000 nor more
than $20,000):
Fixed payment in lieu of the payments for actual moving and related expenses and
actual reasonable reestablishment expenses. .................................................................................. $
I certify that I am the owner or authorized representative of the business, farm or nonprofit organization named
above; that no other claim for reimbursement or compensation for payment of moving expenses or in lieu of moving
expenses has been submitted or payment received, or will be accepted from any other source, by me or on behalf
of said business, farm or nonprofit organization.
In case of a moving claim, I certify that I have moved or have caused to be moved the personal property indicated
on the inventory as having been relocated.
Claimant’s Signature
Title
Date:
Title
Date:
Claimant’s Signature
REMARKS:
I certify that I have examined this claim and the Relocation Determination (CDOT Form #453) with substantiating
documentation submitted in connection with this claim, and have found it to conform to the applicable provision of
State law; this claim is approved and payment is authorized.
Real Estate Specialist signature
Date:
Statewide ROW Program Manager (review and approval)
Date:
cc: Project Development Branch, ROW Services (original)
CDOT Form #436
05/17
Region ROW
Previous editions are obsolete and may not be used
Project Code:
COLORADO DEPARTMENT OF TRANSPORTATION
Parcel No:
MOVING OR IN LIEU PAYMENT CLAIM
Project No:
Location:
(Business, Farm or Nonprofit Organization)
County:
Claimant’s name:
State acquired property address or location:
Replacement property address or location:
Name of Business, Farm, or Nonprofit Organization:
Moves from a business, farm or nonprofit organization (based on one or a combination of the following methods:
1) Commercial Move (based on the lower of two bids or estimates) ............................................... $
2) Self Move (based on one or a combination of the following):
a) Lower of two bids .................................................................................................................. $
b) Supported by receipted bills for labor and equipment. Hourly rates should not exceed
those paid by commercial movers for labor and equipment rental........................................ $
Eligible Actual Moving Expenses for a Business, Farm, or Nonprofit Organization:
Searching for a replacement location (not to exceed $2,500) ......................................................... $
Storage of the personal property for a period not to exceed 12 months ........................................... $
$
$
$
$
$
Related Nonresidential Eligible Expenses:
Connection to available nearby utilities from the right of way to improvements at the
replacement site. ............................................................................................................................... $
Professional Services performed prior to the purchase or lease of a replacement site. .................. $
Impact fees or one time assessments for anticipated heavy utility usage. ....................................... $
Reestablishment expenses – Nonresidential Moves (not to exceed $10,000) ................................. $
Fixed Payment for Moving Expenses – Nonresidential Moves (Not less than $1,000 nor more
than $20,000):
Fixed payment in lieu of the payments for actual moving and related expenses and
actual reasonable reestablishment expenses. .................................................................................. $
I certify that I am the owner or authorized representative of the business, farm or nonprofit organization named
above; that no other claim for reimbursement or compensation for payment of moving expenses or in lieu of moving
expenses has been submitted or payment received, or will be accepted from any other source, by me or on behalf
of said business, farm or nonprofit organization.
In case of a moving claim, I certify that I have moved or have caused to be moved the personal property indicated
on the inventory as having been relocated.
Claimant’s Signature
Title
Date:
Title
Date:
Claimant’s Signature
REMARKS:
I certify that I have examined this claim and the Relocation Determination (CDOT Form #453) with substantiating
documentation submitted in connection with this claim, and have found it to conform to the applicable provision of
State law; this claim is approved and payment is authorized.
Real Estate Specialist signature
Date:
Statewide ROW Program Manager (review and approval)
Date:
cc: Project Development Branch, ROW Services (original)
CDOT Form #436
05/17
Region ROW
Previous editions are obsolete and may not be used

Download CDOT Form 436 Moving or in Lieu Payment Claim ((Business, Farm or Nonprofit Organization) - Colorado

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