To be prepared by the Right-of-Way Agent, immediately after each contact and transmitted to the District Right-of-Way Office. Entry for each contact to contain as a minimum: date and place of contact, persons present, subjects of discussion and as appropriate, offers made, counter offers, areas of agreement or disagreement, and commitments by the Right-of-Way Agent, etc.

ITEMS CHECKED AT COURTHOUSE

Ownership	☐ Same	☐ Change *
* If an ownership change has occurred since the title commitment was issued, include copies of ownership change documents in the acquisition package

Mortgages/Trust Indentures	☐ Yes *	☐ No
☐ Satisfied (attach copy of release/satisfaction
* If compensation (less cost to cure) is over $25,000 include complete copies of current mortgages/trust indentures in the acquisition package

LANDOWNER INFORMATION
Landowner Name, Address & Phone # (address should indicate where copy of completed agreement should be mailed)
enter name & address

Telephone:	Home: enter text	Work: enter text	Other: enter text
E-Mail Address:	enter text

Date	Entry

STATEMENT OF RIGHT-OF-WAY AGENT I CERTIFY: The Right–of–Way Agreement dated choose a date. embodies all considerations agreed to between the undersigned and the landowners. A Highways brochure, Title VI brochure, written offer and summary statement have been given to all landowners and the proposed project explained and described to the best of my ability. The Agreement was reached without coercion or threats of any kind by either party. That, I, as Right-of-Way Agent on this parcel(s) have no direct, indirect, present or contemplated future personal interest in the parcel(s) or in any benefit from the acquisition of the subject property.

ELECTRONIC SIGNATURE CONSENT

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications or misrepresentations.

Signature (Typed Name)	Date	Place of Signature (City, State)
Choose a date

Right-of-Way Agent

Consultant Signature (if applicable)	Date

Consultant Contact Info
enter name & address

Telephone:	enter text	E-Mail Address:	enter text