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

1.	RE-ESTABLISHED

A.	Replacement cost of item(s) minus net proceeds of sale (attach receipts, Bill of Sale etc.)	$amt
B.	Estimated moving cost of item(s)	$amt
Amount due owner (lesser of A or B)	$amt

2.	DISCONTINUED

A.	Estimated value of item(s) in place minus net proceeds of sale (attach receipts, Bill of Sale, etc.)	$amt
B.	Estimated moving cost of item(s)	$amt
Amount due owner (lesser of A or B)	$amt

3.	SALE EXPENSE

Reasonable sale expenses	$amt

Total of 1 OR 2 plus 3	$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)

MDT Relocation Agent