Relocatee:	enter text	Project No.:	enter text
Address:	enter text	Designation:	enter text
enter text	Parcel No.:	enter text
Moved to:	enter text	Telephone No.:	enter text
enter text	Distance Moved:	enter text

Moving Estimates by Qualified Mover (attached bids)	Lowest Bid:	$enter 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)

Approved by Relocation Supervisor

Actual moving expense by qualified mover (attach receipts)	$enter amt
Actual moving expense by self-move (attach receipts)	$enter amt
Incidental moving expense (attach itemized receipts and explain)	$enter amt
TOTAL MOVING EXPENSE	$enter 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.

I/We hereby certify that the above move was completed on:

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

Relocatee

I inspected the premises on	and the above move described has been completed.

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

MDT Relocation Agent