Relocatee:	enter text	Project No.:	enter text
Address:	enter text	Designation:	enter text
Telephone No.:	enter text	Parcel No.:	enter text

Yes	No
Conforms with any/all applicable State, County or local codes and ordinances.
Has an adequate supply of safe drinking water.
Has a kitchen or kitchen area with sink, space and service connections for a stove and refrigerator.
Has an adequate and operating heating system for the living areas.
Has a bathroom with lavatory, flush toilet, bathtub or stall shower.
Has provision for artificial lighting in each room.
Appears to be structurally sound, in good repair and adequately maintained.
Has safe, unobstructed means of egress to ground level.
Has legal sewage disposal system connected to all lavatories, sinks, bathtubs, showers and flush toilets.
Has 150 square feet of habitable floor space for a single occupant, and 100 square feet of habitable floor space for each additional occupant, except for rented sleeping rooms which are to have 100 square feet for the first occupant and 50 square feet for each additional occupant.

Subject owner has relocated to:	Click to enter text

I have inspected the new dwelling and found it to be decent, safe, and sanitary. Supplemental housing payment can be made. I understand that this determination is to be used in conjunction with a federal-aid project. I have no direct, indirect, present or contemplated personal interest in this transaction, nor will I derive any benefit from the supplemental payment.

APPROVED:

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

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

MDT Acquisition Manager