Missouri Highway and Transportation Department

MISSOURI HIGHWAY AND TRANSPORTATION DEPARTMENT RIGHT OF WAY DIVISION-NEGOTIATOR’S REPORT COUNTY ROUTE PARCEL 60-DAY NOTICE JOB # DATE OWNER RACE PHONE & ADDRESSES REPRESENTED BY ATTORNEY & ADD PHONE TENANTS AND ADDRESSES PHONE REPRESENTED BY PHONE ATTORNEY & ADDRESS OTHER Donation: PHONE INTEREST TO ACQUIRE Yes No OFFER/SETTLEMENT FEE TENANTS INT. TOTAL REMNANT (S) APPROVED OFFER: FEE OWNERS $ $ $ $ REVISED OFFER: FEE OWNERS $ $ $ $ ADMINISTRATIVE SETTLEMENT $ $ $ $ HERITAGE $ $ $ $ HOMESTEAD $ $ $ $ REMNANT $ $ $ $ IMPROVEMENTS IN RIGHT OF WAY FEE OWNED IMPROVEMENTS SAL. VALUE RETAINED AMOUNT $ $ $ $ $ $ TENANT OWNER IMPROVEMENTS SAL. VALUE RETAINED AMOUNT $ $ $ $ $ $ RECORD OF NEG.: ATTACH RECORD OF DATE & PLACE OF EACH CONTACT, INTERESTED PERSONS PRESENT, AMOUNT OFFERED, COUNTER OFFERS, REASONS SETTLEMENT NOT MADE & ANY OTHER PERTINENT DATA. Letter of Offer, Deed, To Owner Mailed DATE Mailed To Other DATE & R/W Brochure To Attorney Handed Handed Fee Owners LETTER OFFER, QCD, R/W BROCHURE & DISCLAIMER TENANT # 1 TENANT # 2 TENANT # 3 TENANT # 4 MAILED (LIST DATE IN SPACE PROVIDED) HANDED (LIST DATE IN SPACE PROVIDED)

RA FORM 8-6.5 TO RELOCATION SECTION DATE SIGNED: W.D. CONTRACT DISCLAIMER QCD TENANT REL.

(WHEN APPLICABLE) DATE: RA FORM 8-6.8(b) TO RELOCATION SECTION DATE: ESCROW AGENT ADDRESS PHONE SUMMARY OF SETTLEMENT GROSS SETTLEMENT FOR FEE OWNED R/W $ PLUS REMNANT (S) $ LESS SALVAGE VALUE(S) -$ NET MONETARY CONSIDERATION TO FEE OWNER $

Tenant Interest $

Tenant Interest - Signs $

Others $

Less Salvage Value(s) -$ Net Monetary Consideration to Tenants $ TOTAL NET SETTLEMENT (SPECIAL AGREEMENTSLIST AND ATTACH ON A SEPARATE SHEET) $ SIGNS ACQUIRED NO YES IF YES, WERE THEY LEGAL ILLEGAL I, the undersigned, certify (the executed instrument(s) and this report embody all of the considerations agreed upon with the owner(s), without coercion, promises, or threats by or to either party, and that) I have no direct, indirect, present or contemplated future personal interest in this parcel or any benefits from the acquisition of this parcel; and I understand this parcel is to be used in connection with a Federal-Aid Highway Project. SIGNATURE TITLE DATE 

EPG 236.7.2 Page 1 of 1 Form 7.2.12A 08/2016