Relocatee:	enter text	Project No.:	enter text
Moved From:	enter text	Designation:	enter text
Moved To:	enter text	Parcel No.:	enter text
Distance Moved:	enter text	Telephone No.:	enter text

Mobile Home Moving Cost (Attach paid receipts and explain)

Moving Estimates by Qualified Mobile Home Mover (attached bids)	Lowest Bid:	$amt

Fixed Moving Cost (Scheduled) Dwelling (Occupant owns furniture)

1 room $550	2 rooms $750	3 rooms $950	4 rooms $1,150	5 rooms $1,350	6 rooms $1,650	7 rooms $1,750	8 rooms $1,950	Add. Rooms $200/ea
amt	amt	amt	amt	amt	amt	amt	amt	amt

Fixed Moving Cost (Scheduled) Dwelling (One Room – No Furniture)

First room - @ $350.00	$amt
Additional rooms @ $100/room	$amt
Total Fixed Moving Costs	$amt

Actual Moving Cost (Attach paid receipts and explain)

Moving Cost	$amt

Estimate Moving Cost by self (Attach paid receipts and explain)

Moving Cost	$amt

Incidental Moving Expense (Attach paid receipts and explain)

enter incidental expense	$amt
Total Incidental Moving Expenses	$amt

Storage Expenses (Attach paid receipts and explain)

Storage Expenses	$amt

Total Moving Costs (select one cost from 1 thru 5) plus Incidental Moving and Storage Expenses	$amt

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)

MDT Relocation Agent