Project ID:	enter text	Project No.:	enter text
Designation:	enter text	Parcel #:	enter text
Property Type:	enter text	Occupancy Type:	Choose an item
Relocatee:	enter text	Phone #:	enter text
Address:	enter text

As you may or may not be aware, the Montana Department of Transportation has begun activities leading to the eventual purchase of additional right-of-way necessary for construction of the project referenced above. The personal property you own may be affected by this project and, will be displaced because of the project.

The Department of Transportation has a relocation assistance program available to all persons displaced by the project. Displaced Person means any person, business, non-profit organization, or farm that moves from real property or moves personal property from real property that is required for the project. This program includes all necessary relocation advisory services, help in filing claims for payment and other necessary assistance to provide for successful relocation. You must move your personal property prior to the project award date choose date to receive this reimbursement, but no displaced person will be required to move personal property within at least 90 days of this advanced written notice, you may also receive a 30-day notice to vacate if your personal property is not moved within 30 days of the MDT project ready date.

All relocation benefits will be open to all persons regardless of color, religion, sex, or national origin. If you are displaced by the project, you have the right to appeal to the Department's determination regarding eligibility for, or the amount of, any relocation payment for which you are eligible. Any displaced person who is an alien not lawfully present in the United States is ineligible for relocation advisory services and relocation payments, unless such ineligibility would result in exceptional and extremely unusual hardship to a qualifying spouse, parent, or child.

Payment will be made when the landowner has notified the MDT Right of Way Agent that the personal property has been moved and the Right of Way Agent is able to verify.

RATE TABLE

STEP 1

Inventory of relocation items, description of personal property move(s), and estimated cost: enter text

The undersigned relocate(s), being the occupant(s) of the property being acquired by the Montana Department of Transportation (MDT), do(es) hereby make application for relocation assistance payment as follows:

Moving costs or in the amount of	$amt
Moving costs or in the amount of	$amt
Moving costs or in the amount of	$amt
Total Relocation Payment of	$amt

I was the owner-occupant/tenant who owned or occupied my previous dwelling or business for a minimum of 90 days before negotiation for the property began.

I/We the undersigned do hereby agree to assign compensation as follows:

$enter amt to enter name

☐ A warrant mailed to the following address: enter address

☐	Direct deposit per the information on the 204 DOA form

Note: Relocatee(s) must provide MDT with an IRS W-9 form completed and signed by Assignee if not previously provided. Normal payment processing time is 4-6 weeks

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 certify that we are U.S. citizens; U.S. Resident Aliens, Aliens lawfully present in the U.S.; a partnership, corporation, company, estate, domestic trust, or association created or organized in the U.S. I/We understand that we are required by law to provide our correct taxpayer identification number(s) to the Montana Department of Transportation and that failing to comply may subject us to civil and criminal penalties. I/We certify that I/We have each submitted to MDT either a W-9 form (IRS Request for Taxpayer Identification Number and Certification) or applicable W-8 form (IRS Certificate of Foreign Status of Beneficial Owner for U.S. Tax Withholding and Reporting).

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 property, nor will I derive any benefit from the relocation payment.

Note~ A page break has been entered at this section to keep signatures separated.

STEP 1 STATEMENT OF RIGHT OF WAY 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. Upon completion of Step 1, I have notified the Relocation Specialist.

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

Right of Way Agent

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

District Right of Way Supervisor

Note ~ If using DocuSign for signatures separate Steps 1 and 2 .

STEP 2 STATEMENT PROPERTY HAS BEEN MOVED 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 CERTIFY: The personal property described above has been relocated from MDT’s Right of Way and I am now entitled to receive the relocation payment.

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

Relocatee

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

Right of Way Agent

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

Right of Way Relocation Specialist

Note~ A page break has been entered at this section to keep history documentation separated.

HISTORY

Date & Entry