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

Choose either Business/Non-Profit or Farm/Ranch

DETERMINATION OF PAYMENT

* The term “average annual net earnings” means one-half of net earnings before Federal, State, and local income taxes during the 2 taxable years immediately preceding the taxable year in which the business is relocated.

½ of Annual Net Income	Year enter year	$enter income	Attach verification
½ of Annual Net Income	Year enter year	$enter year	Attach verification
Total for 2-year period = $enter $ divided by 2 = $enter $
(If average net 2-year income is less than $1,000, pay $1,000. If average net 2-year income is between $1,000 and $40,000, pay the average net income. In no case may the payment be less than $1,000 nor more than $40,000.)

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

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

NOTE: Include all necessary attachments and histories.