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

☐ Business	☐ Farm or Ranch	☐ Non-profit Organization

RE-ESTABLISHED

1.	Replacement cost of item(s)	$enter amt
Minus net proceeds of sale (attach receipts, Bill of Sale etc.)	$enter amt
2.	Estimated moving cost of item(s)	$enter amt
Amount due owner (lesser of 1 and 2)	$enter amt

DISCONTINUED

1.	Estimated value of item(s) in place	$enter amt
Minus net proceeds of sale (attach receipts, Bill of Sale etc.)	$enter amt
2.	Estimated moving cost of item(s)	$enter amt
Amount due owner (lesser of 1 and 2)	$enter amt

NO-EFFECTIVE SALE

1.	Reasonable sale expenses	$enter amt
2.	Estimated moving cost of item(s)	$enter amt
Amount due owner (lesser of 1 and 2)	$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)

Relocatee

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

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

MDT Relocation Agent