Project No.:	enter text	Relocatee:	enter text
Parcel No.:	enter text	Address:	enter text
Designation:	enter text	Phone #:	enter text

YES	NO
Is this the last relocation payment for this parcel on the project?	☐	☐
If YES, attach completed 399 to this form

Choose a building block.

TOTAL RELOCATION PAYMENT	$enter total

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