Right-of-Way Bureau

Department of Transportation

2701 Prospect Avenue

PO Box 201001

Helena, MT 596020-1001

Subject:	Project ID.:	enter text

Project No.:	enter text

Designation:	enter text

Parcel No.:	enter text

Please be informed that I fully understand that any relocation assistance payments for which I may be eligible do not in any manner affect or influence the present market value of all or any portion of my property and do not, under any circumstances, constitute a part of the consideration for highway right-of-way acquired or to be acquired from me.

I am not represented by legal counsel, or any other agent acting in my behalf, to arrange for payment of any relocation assistance payments for which I may be eligible.

In view of the above statements, I request your Relocation Agent to contact me directly to discuss my eligibility for relocation assistance payments and to arrange for any such payments to be made directly to me.

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