MISSOURI DEPARTMENT OF TRANSPORTATION RIGHT OF WAY DIVISION RIGHT OF WAY ACQUISITION PAYMENT FS: R2 Submitted by: Date: Job No: Suffix: County: Route: Parcel: No. of Negotiate Award Judgment Parcels d Acquired MHTC Case No. Vs. Exception of Type of Payment: Regular Relocation Prorata Condemnation TYPE AND AMOUNT OF PURCHASE

1. Regular Purchase Square Feet: $ 2. Excess $ 3. Uneconomic Remnant Square Feet: $ 4. Permanent Easement (Object 2820, Sub-Object 05) Square Feet: $ (Fixed Asset “P”) 5. Temporary Easement (Constr., Borrow, Waste, etc.) Square Feet: (Object 2820, Sub-Object 05) (Fixed Asset “O”) $ 6. Relocation Costs $ 7. Other: ($0.00 ) $ ($0.00 ) $ 0.0=(text43+text44) 8. Total Lines 1 thru 7 $ 0.0=(Text9+Text10+T ext11+Text12+Text14 +Text15+Text43+Tex t44) 9. Award Previously Paid into Court $ 0.00 10. Amount of Check (Line 8 less line 9) $ 0.0=C9-C10 Property Owner or Tenant Name: CHECK PAYABLE TO: VENDOR NUMBER – Only last 4 digits of SS# for individuals/ Last 6 digits for all others of SS# or TIN, or Misc for the Miscellaneous. coding: VENDOR ADDRESS: 1099-S REPORTABLE BY MoDOT (Required) Yes No If yes, the 1099S page must be added in RWPA. Admin. Purchase Escrow Legal Forms Claim Form Deed attached: Settlement Agreement Agreement Documents The undersigned certifies the above information has been checked against this district’s records and it is a just and correct payment.

Signature Date Title TO BE COMPLETED BY THE DISTRICT RIGHT OF WAY UNIT Line Fixed Fund Agency Org. Appr. Object Sub- Activity Amt. FMS Job No. Asset Unit Obj 01 0320 605 4403 $ 02 0320 605 4403 $ 03 0320 605 4403 $ 04 0320 605 4403 $

A-419 06/2016 05 0320 605 4403 $ Additional Comments:

TO BE COMPLETED BY FINANCIAL SERVICES Name of Payee is same as on document Amount is same as on document Distribution on code block is correct Parcel numbers, parcel count, and payment type entered on PVQ document Document is certified TMS Input Needed Checked by

A-419 06/2016