Relocatee:	enter text	Project No.:	enter text
Address:	enter text	Designation:	enter text
enter text	Parcel No.:	enter text
Moved to:	enter text	Telephone No.:	enter text
enter text	Distance Moved:	enter text

Actual Moving Cost (Attach paid receipts and explain)

Moving Cost	$amt

Estimate Moving Cost by self (Attach paid receipts and explain)

Moving Cost	$amt

Storage Expenses (Attach paid receipts and explain)

Storage Expenses	$amt

Searching Expense (Explain, include paid receipts)

$amt

Re-Establishment Expense

Re-establishment Expense (not to exceed $33,200)	$amt
Fixed in lieu of payments for actual moving & related expenses and re-establishment expenses (not less than $1,000 or more than $53,200) Attach form MDT-ROW-364	$amt

Total Moving Costs (select one cost from 1 or 2) plus Storage, Searching and Re-establishment Expenses	$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.

I/We hereby certify that the above move was completed on:

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

Relocation Agent