Date:	Choose date	Letting Date:	Choose date

In connection with these projects, the following is a tabulation and status report of relocation assistance given or offered to persons displaced by these projects.

Project No.:	enter text	Designation:	enter text

Parcel	Relocatee Name	Residential or Business Relocation	Owner or Tenant	Displacee has been relocated from subject property?	Displacee not relocated yet but will be prior to letting	Displacee will not be relocated prior to letting. Special provision was distributed
No.	enter name	Choose	Choose	Choose	Choose	Choose
No.	enter name	Choose	Choose	Choose	Choose	Choose
No.	enter name	Choose	Choose	Choose	Choose	Choose
No.	enter name	Choose	Choose	Choose	Choose	Choose
No.	enter name	Choose	Choose	Choose	Choose	Choose

Notes:	enter text

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.

I understand that this determination is to be used in conjunction with a Federal-Aid highway project. I have no direct, indirect, present, or contemplated personal interest in this property, nor will I derive any benefit from the supplemental payment.

Signature (Typed Name)	Date	Place of Signature (City, State)

MDT Relocation Agent