Project ID.:enter text

Project No.:enter text

Designation:enter text

Parcel No.:enter text

Please complete the information to receive electronic communication.

Preferred Method of Communication:

☐ Email/ Electronic Communication

Electronic communication may include DocuSign, a secure cloud-based platform that enables users to electronically sign, send and manage documents

Displacee Name: enter text

Displacee Email address: enter text

Displacee Phone number: enter text

Displacee Representative Name (if applicable): enter text

Displacee Representative Email address (if applicable): enter text

Displacee Representative Phone number (if applicable): enter text

The Montana Department of Transportation certifies that electronic notices and signatures will be consistently applied in conformity with State and Federal laws.

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

Displacee

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.

If you would like to change communication methods in the future to contact the Relocation Agent.