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

The Business, Farm/Ranch Operation, or Non-Profit entity is eligible to receive fixed payment for moving expenses per the eligibility requirements outlined in 49 CFR 24.305.

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 Choose an item	Year enter year	$enter income	Attach verification (Redact PII information)
½ of Choose an item	Year enter year	$enter income	Attach verification (Redact PII Information)
Average for 2-year period = $enter
(If the average net 2-year income is less than $1,000, pay $1,000. If the average net 2-year income is between $1,000 and $53,200, pay the average net income. In no case may the payment be less than $1,000 nor more than $53,200.)

NOTE: Include all necessary attachments and histories. Redact PII verification attached.

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