Illinois Department of Transportation, Ann L. Schneider, Secretary
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 Patrick J. Quinn, Governor
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BUREAU OF LAND ACQUISITION
LISTING OF EXHIBITS, FORMS AND TEMPLATES

Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | Chapter 7 | Chapter 8 | Chapter 9

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CHAPTER 1 – OVERVIEW AND QUALIFICATIONS

Exhibit Form Template Description
  LA 161   Application for Assignment as Land Acquisition Fee Agent(s)

CHAPTER 2 – RIGHT OF WAY ENGINEERING   

Exhibit Form Template Description
LA 221     Typical Tract Designation, Parcel Number Elements and Numbering Examples
LA 222A     Right of Way Plans – Example Cover Sheet
LA 222B     Right of Way Plans – Example Plan Sheet
LA 22211     Excess Right of Way Examples
LA2228A     Access Control Line Examples of Intersecting Highways and Railroads
LA 2228B     Access Control Line Examples at Bridges and Culverts
    LA 223A Check Sheet - Right of Way Plans-Cover Sheet
    LA 223B Check Sheet - Right of Way Plans-Plan Sheet
LA 2342     Principal Meridians and Baselines of Illinois and Surrounding States
LA 2343A     Rectangular System of Surveys
LA 2343B     Subdivision of Sections
LA 2353A     Monument Record - Example
    LA 239 Entry Upon Lands - Sample Letter
LA 246     Corridor Protection Map and Document Examples
    LA 248A Surveyor's Affidavit of Corrections
LA 255     Right of Way Plats and Metes and Bounds Descriptions – Examples
LA 272     Metric Conversion Tables
LA 276A     Metric Right of Way Plats and Metes and Bounds Descriptions – Example
LA 276B     General Metric Examples

CHAPTER 3 – APPRAISAL AND APPRAISAL REVIEW POLICIES AND PROCEDURES

Exhibit Form Template Description
    LA 33A Appraisal Report and Instructions (Complex and Non-Complex)
    LA 33B Waiver Valuation and Instructions
    LA 33D Valuation Finding Appraisal
    LA 394 Land Economic Studies Sales Data
    LA 396 Land Economic Studies Personal Interview
    LA 397A Land Economic Studies (Residential)
    LA 397B Land Economic Studies (Rural)
    LA 397C Land Economic Studies (Commercial)
LA 397D     Property Sketch
    LA 3729 Appraisal Review Certification and Instructions
LA 37134     Standards for Valuing Release of Dedicated Land and Access Rights

CHAPTER 4 – NEGOTIATION AND ACQUISITION POLICIES AND PROCEDURES

Offer Packet

Exhibit Form Template Description
    LA 415 Introductory Letter
    LA 416 Introduction and Offer Package Letter
    LA 416A Offer Package Letter
  LA 416E   Basis for Computing Total Approved Compensation and Offer to Purchase
  LA 416G   Request for Approval to Purchase Property Over $250,000
    LA 419 Donation Letter
    LA 4110 Negotiator's Report
  LA 4111   Offer to Purchase Uneconomic Remnant
    LA 4113A1 Tenant-Owned Improvement Compensation and Offer to Purchase
    LA 4113C Introductory/Offer Letter for Tenant-Owned Improvements – Staff Negotiator

Deeds

Exhibit Form Template Description
    LA 410A Warranty Deed (Individual) (Non-Freeway)
    LA 410B Warranty Deed (Individual) (Freeway)
    LA 410C Warranty Deed (Corporation) (Freeway)
    LA 410D Warranty Deed (Corporation) (Non-Freeway)
    LA 410D1 Warranty Deed (Limited Liability Company) (Freeway)
    LA 410D2 Warranty Deed (Limited Liability Company) (Non-Freeway)
    LA 410D3 Warranty Deed (General Partnership) (Freeway)
    LA 410D4 Warranty Deed (General Partnership) (Non-Freeway)
    LA 410D5 Warranty Deed (Limited Partnership) (Freeway)
    LA 410D6 Warranty Deed (Limited Partnership) (Non-Freeway)
    LA 410D7 Warranty Deed (Donation) (Individual) (Freeway)
    LA 410D8 Warranty Deed (Donation) (Individual) (Non-Freeway)
    LA 410D9 Warranty Deed (Donation) (Corporation) (Freeway)
    LA 410D10 Warranty Deed (Donation) (Corporation) (Non-Freeway)
    LA 410D11 Warranty Deed (Governmental Entity) (Freeway)
    LA 410D12 Warranty Deed (Governmental Entity (Non-Freeway)
    LA 410E Trustee’s Deed  (Individual) (Freeway)
    LA 410F Trustee’s Deed  (Individual) (Non-Freeway)
    LA 410G Trustee’s Deed (Corporation) (Freeway)
    LA 410H Trustee’s Deed (Corporation) (Non-Freeway)
    LA 410I Dedication of Right of Way (Individual) (Freeway)
    LA 410J Dedication of Right of Way (Individual) (Non-Freeway)
    LA 410J1 Dedication of Right of Way (Corporation) (Freeway)
    LA 410J2 Dedication of Right of Way (Corporation) (Non-Freeway)
    LA 410S Special Warranty Deed (Corporation) (Freeway)
    LA 410T Special Warranty Deed (Corporation) (Non-Freeway)
    LA 410U Quitclaim Deed (Corporation) (Freeway)
    LA 410V Quitclaim Deed (Public Utility, Corporation) (Non-Freeway)
    LA 410W Quitclaim Deed (Individual)
    LA 410Z Executor’s Deed (Individual) (Freeway)
    LA 410Z1 Executor’s Deed (Individual) (Non-Freeway)
    LA 410Z2 Executor’s Deed (Corporation) (Freeway)
    LA 410Z3 Executor’s Deed (Corporation) (Non-Freeway)
    LA 410AB Warranty Deed (School District) (Freeway)
    LA 410AC Warranty Deed (School District) (Non-Freeway)
    LA 410AD Quitclaim Deed (Individual Trustee) (Freeway) - NEW
    LA 410AE Quitclaim Deed (Individual Trustee) (Non-Freeway) - NEW
    LA410AF Quitclaim Deed-Trustee (Corporation) (Freeway) - NEW
    LA410AG Quitclaim Deed-Trustee (Corporation) (Non-Freeway) - NEW
    LA410AH Easement Holder’s Consent to Temporary Construction Easement (Corporation) - NEW

Easements

Exhibit Form Template Description
    LA 410K Permanent Easement (Individual)
    LA 410K1 Permanent Easement (Corporation)
    LA 410K2 Permanent Easement (Limited Liability Company)
    LA 410K3 Permanent Easement (Partnership)
    LA 410K4 Permanent Easement (Governmental Entity)
    LA 410K5 Permanent Easement (Trust)
    LA 410K6 Permanent Easement (School District)
    LA 410M Temporary Construction Easement (Individual)
    LA 410M1 Temporary Construction Easement (Corporation)
    LA 410M2 Temporary Construction Easement (Limited Liability Company)
    LA 410M3 Temporary Construction Easement (Partnership)
    LA 410M5 Temporary Construction Easement (Governmental Entity)
    LA 410M6 Temporary Construction Easement (Trust)
    LA 410M7 Temporary Construction Easement (School District)
    LA 410N Scenic Easement

Affidavits

Exhibit Form Template Description
  LA 4111A   Affidavit of Title
  LA 4111B   Disclosure of Owner(s) and/or Beneficial Interest(s) Affidavit (Trust)
  LA 4111C   Disclosure of Owner(s) and/or Beneficial Interest(s) Affidavit (Corporation, Partnership or Limited Liability Company)
  LA 4111D   Disclosure of Owner(s) and/or Beneficial Interest(s) Affidavit (Publicly Traded Corporation)
    LA 4111E Operating Railroad Affidavit
  LA 4412   Certification of Agent Under Power of Attorney
    LA 472 Affidavit of Non-Production
    LA 4113A Disclaimer Affidavit for Tenant-Owned Improvement
    LA 4414 Trust Certification

Receipts/Disbursement Statements

Exhibit Form Template Description
    LA 4112 Receipt for Donation
    LA 4112A Receipt and Disbursement Statement

Releases/Consents

Exhibit Form Template Description
    LA 410M4 Release of Temporary Construction Easement
    LA 492 Freeway Release (Individual)
    LA 492A Freeway Release (Corporation - LLC-Partnership)
    LA 410O Partial Release of Mortgage (Individual)
    LA 410O1 Partial Release of Mortgage (Corporation)
    LA 410P Full Release of Mortgage (Corporation)
    LA 410Q Full Release of Mortgage (Individual)
    LA 410R Tenant’s Release of Lease (Individual)
    LA 410R1 Tenant’s Release of Lease (Corporation-LLC-Partnership)
    LA 410R2 Tenant’s Release of Lease and Consent to a Temporary Construction Easement
    LA 410X Tenant’s Consent to Temporary Construction Easement (Individual)
    LA 410X1 Tenant’s Consent to Temporary Construction Easement (Corporation-LLC-Partnership)
    LA 410Y Mortgagee’s Consent to Temporary Construction Easement (Individual)
    LA 410Y1 Mortgagee’s Consent to Temporary Construction Easement (Corporation)
    LA 410AA Release in Lieu of Waiver of Damage Clause
    LA 471 Release of Surface Rights
    LA 4413A Lessee’s Release of Lease and Agreement to Vacate Advertising Sign
    LA 4413B Lessee’s Release of Lease and Bill of Sale for Advertising Sign

Resolutions

Exhibit Form Template Description
    LA 448 Certified Resolution (Corporation)
    LA 448A Certified Resolution (Limited Liability Company)
    LA 448B Certified Resolution (School District)
    LA 448C Certified Resolution (Condominium Association Corporation)
    LA 448D Certified Resolution (Condominium Association Unincorporated
    LA 448E Certified Resolution (Government Entity)

Notices

Exhibit Form Template Description
    LA 4114A 60-Day Letter
    LA 4114B 60-Day Notice – Tenant Owner
    LA 4114C Restatement of Offer Letter

Miscellaneous

Exhibit Form Template Description
  LA 462   Application for Property Tax Exemption
    LA 48A Subordination of Surface Rights for Public Road Purposes (Federal Aid Interstate Route)
    LA 48B Subordination of Surface Rights for Public Road Purposes
  LA 4121A   Affidavit of Adverse Possession (20 Year)
  LA 4121B   Affidavit of Adverse Possession (Color of Title)
  LA 4122   Title Search Checklist
    LA 417A Agreement with Utility Company to Acquire Substitute Right of Way
    LA 417B Conveyance of Substitute Right of Way to Utility Company
    LA 451 When Purchasing ROW From a State Employee (Sample Letter)
    LA 4246 Cost Estimate for Functional Replacement
    LA 42416 Joint Statement

Crop Damage

Exhibit Form Template Description
  LA 420A   Crop Damage Report
    LA 420B Damage Release
    LA 420C Crop Damage Release

Local Public Agency

Exhibit Form Template Description
    LA 414 Agreement to Replace Property Acquired From a Public Agency
  LA 4192   Standard Agreement Provisions – Joint Improvement on the State Highway System
  LA 4193   Standard Agreement Provisions – Joint Improvement off the State Highway System (Federal Aid Right of Way Projects)
  LA 4194A   Project Compliance Checklist (Local Agency)
  LA 4194B   Parcel Compliance Checklist
  LA 4194C   Parcel Compliance Checklist (Relocation Assistance)

Condemnation

Exhibit Form Template Description
  LA 42312   Eminent Domain Checklist
  LA 4234   Authorization for Filing Quick Take Motion

CHAPTER 5 – RELOCATION ASSISTANCE AND PAYMENTS PROGRAM POLICIES AND PROCEDURES

Exhibit Form Template Description
  LA 58   Claim for Incidental Expenses for Acquired Property
  LA 513   Uniform Act Relocation and Real Property Acquisition Statistical Report
    LA 514 Certification of Citizenship (individual) NEW
    LA 514A Certification of Citizenship (Unincorporated Business, Farm or Non-Profit Organization) NEW
    LA 514B Certification of Citizenship (Incorporated Business, Farm or Non-Profit Organization) NEW
  LA 5134   Relocation Assistance Parcel Check List
  LA 531A   Relocation Plan Interview – Residential
  LA 531B   Relocation Plan Interview – Business
    LA 541A 180-day Relocation Letter
    LA 541B 90-day Relocation Letter
    LA 541C Business Informational Letter – 90-Day Notice
  LA 541D   Relocation Assistance Unit Record
    LA 542 Notice to Vacate
  LA 544   Notice of Receipt of Claim for a Relocation Payment
  LA 564A   Replacement Housing Supplement Comparable Listing
  LA 564B   Payment Evaluation Form for Replacement Housing Supplement (Purchase)
  LA 564C   Replacement Housing Supplement Certification
LA 598     Fixed Residential Moving Cost Schedule
    LA 5664 Mortgage Interest Differential Payments
    LA 5665A MIDP Computation Using HP-12C
    LA 5665B MIDP Computation Using TI Business Analysts or Radio Shack EC-100
  LA 5667A   Claim for Replacement Housing Supplement
  LA 5667B   Dwelling Inspection (Decent, Safe and Sanitary)
  LA 5672   Payment Evaluation Form for Replacement Housing Supplement (Rent)
  LA 5692   Economic Means Evaluation for Low Income Households
  LA 5910   Bid Form for Actual Moving Expenses
  LA 5918   Claim for Moving Expenses
  LA 5103   Itemized Eligible Reestablishment Expenses for Small Business, Farm and Non-Profit Organizations Worksheet
  LA 5109A   Request for Determination of Entitlement for Payment in Lieu of Moving Expenses
  LA 5109B   Notice of Receipt for Determination of Entitlement for Payment in Lieu of Moving Expenses
  LA 51010   Claim for Fixed Payment in Lieu of Moving Expenses

CHAPTER 6 – PROPERTY MANAGEMENT POLICIES AND PROCEDURES

Exhibit Form Template Description
    LA 67 Bill of Sale (Buildings, Goods and Chattels)
LA 611A     Land Conveyance Procedures – Jurisdictional Transfers New JT
LA 611B     Land Conveyance Procedures – Jurisdictional Transfers Past JT
  LA 621   Project Inventory of Improvements
  LA 622   Classification and Disposition Values – Nursery Stock
  LA 623   Improvement Disposition and Rental Values
    LA 631A Retention Agreement
    LA 631B Rental Agreement
  LA 631C   Annual Rental Review
    LA 631D Rental Review Letter to Tenant
    LA 656A Final Demand Letter
    LA 656B Notice and Demand for Possession
  LA 659   Lead-Based Paint Hazard Disclosure to Potential Tenants
  LA 661   Application for Rental
  LA 662   Order and Approval to Dispose of Excess State Property
    LA 668 Emergency Repair Statement
  LA 671   Bidder’s Proposal for Public Sale, Purchase and Removal of State Owned Excess Personal Property
  LA 676   Lead-Based Paint Hazard Disclosure to Potential Purchasers
  LA 681A   Request for Asbestos Survey
LA 681B     Preliminary Asbestos Survey – Building Description and Sketches
    LA 681C Entry Upon the Property Letter to the Tenant
  LA 681D   Consent to Conduct Asbestos Survey
LA 681E     Suggested Items for Inclusion in the Survey Report
LA 691A     Norway Database – Instructions for Data Entry
LA 691B     Norway Database – Instructions for Selection of Report Type
  LA 692   Statement for Disposal of Excess Lands or Rights
  LA 694A   Statement for Transfer of Land Rights Associated with a Jurisdictional Transfer
    LA 694B Legal Description
    LA 694C Agreement for Restoration of Access Rights
  LA 696A   Notice to Bidders and Bidders Proposal for Public Sale and Purchase of State Owned Excess Land
  LA 696B   Disclosure of Ownership Affidavit
    LA 699 Legislative Action Request Letter
  LA 6102A   Application for Use of Surface Area Under Elevated Highway Structures or Adjacent to Highway Facilities
  LA 6102B   Lease Agreement Non-Highway Use (Right of Way)
  LA 6105   Bidder’s Proposal for Leasing Operating Highway Right of Way (Non-Highway Related use) by Sealed Bids or at Auction
  LA 6109   Permit for Use of Surface Area Under Elevated Highway Structures or Adjacent to Highway Facilities
    LA 61010A Inventory and Management of Right of Way Leases
    LA 61010B Lease Index – Operating Highway Right of Way (Non-Highway Related Use)

CHAPTER 7 – ACCOUNTING FOR LAND ACQUISITION SERVICES

Exhibit Form Template Description
  LA 72   Certification (Exclusion of Principal Residence form 1099-S Reporting Requirement)
LA 72A     1099-S/1099-Misc.
LA 76     Right of Way Function Codes and Descriptions
LA 78A     County Codes with District Number
    LA 731A Warrant Requisition Cover Sheet
LA 793A     Archives Records Transfer Sheet
LA 793B     Record Center Box Label
LA 793C     Records Disposal Certificate
LA 794A     Records Transfer Sheet
LA 794B     Microfilm Records Index
LA 7411     Attorney Statement of Services and Affidavit

CHAPTER 8 – ADMINISTRATIVE AND OUTSOURCING

Exhibit Form Template Description
    LA 810 Late Filing Affidavit
  LA 811   Invoice

CHAPTER 9 – OUTDOOR ADVERTISING

Exhibit Form Template Description
  LA 9001   Application for Outdoor Advertising Permit Business Area Sign – Primary Highway
  LA 9002   Application for Outdoor Advertising Permit Business Area Sign – Interstate Highway
  LA 9003   Application for Outdoor Advertising Permit On-Premise Sign – Interstate Highway
  LA 9004   Application for Outdoor Advertising Permit For Sale or Lease Sign – Interstate Highway
  LA 9005   Application for Outdoor Advertising Permit Lodging, Food, Outdoor Recreation or Automotive Service Sign – Interstate Highway
  LA 9008   Notification for Outdoor Advertising Directional or Official Sign
  LA 9009   Transfer of Outdoor Advertising Permit Ownership
    LA 9102 Notice of Irreparable Damage to Sign
    LA 951A Notice of Intent to Deny Permit Application
    LA 951B Notice of Permit Application Approval
    LA 97A 30-Day Letter – Notice of Unlawful Sign (Sign Not Permitted)
    LA 97A1 30-Day Letter – Notice of Unlawful Sign (Sign May Be Permitted)
    LA 97B Notice of Intent to Revoke Permit

 
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