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

Choose an item do not agree with the State’s determination of relocation assistance offered and request a review by the Appeal Board. Choose an item request that Choose an item be notified of the hearing date so that Choose an item may be present. Choose an item certify that the amounts shown below are the figures that were presented to Choose an item by the Relocation Agent.

Supplemental Housing Payment Offered	$amt
Relocatee’s Requested Adjustment (Attach reasons)	$amt
Incidental Property Transfer Expense Offered	$amt
Relocatee’s Requested Adjustment (Attach reasons)	$amt
Moving Expense Offered	$amt
Relocatee’s Requested Adjustment (Attach reasons)	$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)

Relocatee

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

MDT Relocation Agent

Determination of Appeals Board:

The Appeals Board Meeting to consider the above request was held on: enter a date.

The Appeals Board has determined that the request of the relocatee be accepted.

(Letter to Relocatee)