To be prepared by the Relocation Agent, immediately after each contact. Entry for each contact to contain as a minimum: date and place of contact, persons present, subjects of discussion, areas of agreement or disagreement, and dates when Relocation brochure, Title VI brochure, General Notice and 90 Day Notice were given to each Relocatee.

LANDOWNER INFORMATION
Landowner Name, Address & Phone # (address should indicate where copy of completed agreement should be mailed)
enter name & address

Telephone:	Home: enter text	Work: enter text	Other: enter text

Type of Relocation: Choose an item.

If Both, explain: enter explanation

Date	Entry

STATEMENT OF RELOCATION AGENT I CERTIFY: A Relocation Assistance brochure and a Title VI brochure have been given to all landowners and any tenants possibly being displaced from this parcel that are known to me. My determination of Relocation Eligibility for each Relocatee was reached without coercion or threats of any kind by either party. I have no direct, indirect, present or contemplated future personal interest in the parcel(s) or in any benefit from the Relocation Assistance provided on this parcel.

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)
Choose a date

Relocation Agent