2009 aashto soc claim certification...

Do your current specifications require the contractor to "certify", under penalty of law, that his claim is truthful, accurate, etc.? Is this done with a standard form?

2009 AASHTO SOC Claim Certification Survey

State Contact Title Certification ? Form ? Response / CommentsAlabama Jeff Benefield Roadway Const Engr No No A certification is not required by the specifications.

Alaska Chuck CorreaRegional Construction Engineer Yes No

In Alaska, our claim spec requires "A certification signed by the contractor that the claim is made in good faith, that the supporting cost and pricing data are accurate and complete to the best of the contractor's knowledge

Arkansas Mike SebrenState Construction Engineer Yes No

We do not have a form for the Contractor to submit certifying these issues. However, our specifications do state the comments below. When submitting a claim, the Contractor must certify in writing, under oath according to the formalities required, as to the following: (1) The claim is made in good faith (2) Supportive data are accurate and complete to the Contractor's best knowledge and belief (3) The amount of the claim accurately reflects the actual cost incurred by the Contractor.

Connecticut James ConneryTransportation Principle Engineer Yes No

ConnDOT does not have a certification form, however, we do require the contractor to certify its claim in accordance with our claim specification, Section 1.11.05 (h) Connecticut specification

Delaware Bill Stewart Area Engineer Yes No

Delaware does require certification with the following language: "The undersigned is duly authorized to certify this claim on behalf of (the Contractor ). (The Contractor ) certifies that this claim is made in good faith, that the supporting data are accurate and complete to the best of the Contractor's knowledge and belief, and that the amount requested accurately reflects the Contract adjustment for which (the Contractor ) believes that the Department is liable." followed with a signature. Delaware specification

District of Columbia Ardeshir Nafici

Acting Associate Director, Infrastructure Project Management Administration Yes No

We do not have Claim Certification Form, but any claim by a Contractor against the District is required to be certified by the Contractor . This requirement is well defined in DDOT Standard Specifications for Highways and Structures ,Section 103 Article 7. District of Columbia specification

Florida David SadlerDirector, Office of Construction Yes No

No standard form for certification. We are considering development of one. Current specification language for claims certification is: 5-12.9 Certificate of Claim: When submitting any claim, the Contractor shall certify under oath and in writing, in accordance with the formalities required by Florida law, that the claim is made in good faith, that the supportive data are accurate and complete to the Contractor’s best knowledge and belief, and that the amount of the claim accurately reflects what the Contractor in good faith believes to be the Department’s liability. Such certification must be made by an officer or director of the Contractor with the authority to bind the Contractor.

Georgia Greg Mayo Director of Construction Yes Yes Georgia Claim Certification form

Idaho Fran Hood State Const Engr Yes No Certification is required by specifications. Idaho specification

Illinois Roger Driskell Chief of Construction Yes No We require a certification in our specifications (109.09). Illinois specification

Indiana Greg PankowState Construction Engineer Yes No Indiana requires claims to be certified. Indiana specification

Iowa John SmytheState Construction Engineer No No The Iowa DOT does not currently require claims to be certified, but we are considering making it a requirement

Kansas Roy Rissky

Chief, Bureau of Construction and Maintenance No No We do not require any certification.

Louisiana Brian BuckelChief, Construction Division Yes No

We do require a sworn statement by the contractor, his bookkeeper, or accountant certifying that the statement and the records from which they were derived are true and correct.

MaineRichard Crawford Asst Program Manager No No Maine does not require a certification.

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State Contact Title Certification ? Form ? Response / Comments

Maryland David PeakeDeputy Director, Office of Construction Yes No

Maryland does require a certification by a senior official, officer, or general partner of the Contractor or subcontractor, as applicable, that, to the best of the person’s knowledge and belief, the claim is made in good faith, supporting data are accurate and complete, and the amount requested accurately reflects the Contract adjustment for which the person believes the Administration is liable. Attached is a copy of our specifications for claims and disputes. Maryland specification.

Massachusetts Michael McGrath Director of Construction Yes No

Yes, Massachusetts Standard Specifications (Subsection 7.16) do require the Contractor to certify a claim in writing ( see http://www.mhd.state.ma.us/downloads/manuals/1995Mspecs.pdf ). A standard form is not required, but a suggested format is provided to Contractors for their use. Massachusetts specificaion

Michigan Brenda O'Brien

Engineer of Construction and Technology Yes Yes Michigan DOT does require certification. Michigan Claim Certification Form

Minnesota Mike LeegardConstruction Support / Claims Engineer Yes No Yes, MN/DOT does have a format as part of our claim specification. Minnesota specification

Mississippi Brad LewisState Construction Engineer Yes Yes Certification is required at time of notice of claim MDOT Notice of Claim Form

Missouri David AhlversState Construction and Materials Engineer Yes No Certification is required by the specifications. Missouri specification

MontanaKevin Christensen Construction Engineer Yes Yes Montana does require a claim certification form. Montana Certified Claim form

Nebraska Claude OieConstruction Division Engineer No No No, but we plan on doing so soon.

New Hampshire Theodore KitsisAdministrator, Bureau of Construction Yes No NHDOT does require the Contractor to certify a claim in specification 105.18. NHDOT specification

New Mexico Joe GarciaState Construction Engineer No No We do not require a certification.

New York Jim TynanDirector, Office of Construction Yes No Certification is required by specifications. NYS specification

North Carolina Ellis PowellState Construction Engineer Yes Yes

We have a claim submission form and the form has a place to certify the claim. North Carolina Contractor Claim Submittal form

North Dakota Cal Gendreau Construction Engineer Yes NoNorth Dakota does require that a Contractor's claim be submitted with a certification. The format is shown in our 2008 Specification in Section 104.06 B.3. North Dakota specification

Ohio Gary AnglesState Construction Engineer Yes No Ohio does not have a standard form but requires the Contractor to certify the claim. Ohio specification

OklahomaGeorge Raymond

Division Engineer, Construction Division Yes No

Oklahoma does require that a "Certificate of Claim" be submitted by the Contractor along with his claim. The format is shown in our 1999 Specification in Subsection 105.18(b). Oklahoma specification

Oregon Jeff GowerState Construction and Materials Engineer Yes No

Oregon DOT specifications do require the Claim to be certified. See Section 199.30(9) for the exact language in our specifications. Oregon Specification.

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State Contact Title Certification ? Form ? Response / Comments

Pennsylvania Tucker FergusonState Construction Engineer No No Pensylvania does not require a certification.

Rhode Island Frank Corrao

Deputy Chief Engineer / Construction Management Yes No

Rhode Island does not have a form, however our specifications require all claims are submitted and certified to the Department in writing. Rhode Island specification

South Carolina Charles Eleazer Construction Engineer Yes Yes Certification is required by form. South Carolina Claim Certification form

South Dakota Jason HumphreyProgram Manager - Operations Yes Yes South Dakota requires a form to be submitted. South Dakota Claim Certification form

Tennessee Brian Egan Director of Construction No No Tennessee does not require a certification, but does have a false claim laws.

TexasThomas Bohuslav

Director, Construction Division Yes No

We do have a certification statement as follows: "I certify that the claim is made in good faith; that the supporting data are accurate and complete to the best of my knowledge and belief; that the amount requested accurately reflects the contract adjustment for which the contractor believes the department is liable; and that I am duly authorized to certify the claim on behalf of the contractor."

Utah Kris PetersonDirector of Construction/Materials Yes No Utah does require a ceritfication. It is described in the specification. Utah specification

Virginia Daniel ListonConstruction Management Engineer Yes No

We have a required certification that must be submitted with the Contractor's claim. Specification reference is 105.19. Virginia specification

West Virginia Darrell AllenDeputy State Highway Engineer, Construction No No West Virginia does not require a certification.

Wisconsin Donald Greuel Project Services Chief Yes No Yes, certification is required by the specifications. Wisconsin specification

Wyoming Mark EisenhartState Construction Engineer Yes No

Yes, Subsection 105.15.2 requires the Contractor to certify but we do not require a separate form as such. Wyoming specification

339 No, Certification Not Required

Yes, Certification Required (7 By Form, 26 by Specification)

Note: Not all certifications include the language "under penalty of law"

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Connecticut Claim Specification and Certification Requirements 1.11.05 – Required Claim Documentation: All claims shall be submitted in writing to the Commissioner, and shall be sufficient in detail to enable the Engineer to ascertain the basis and the amount of each claim, and to investigate and evaluate each claim in detail. As a minimum, the Contractor must provide the following information for each and every claim and sub-claim asserted:

(a) A detailed factual statement of the claim, with all dates, locations and items of work pertinent to the claim.

(b) A statement of whether each requested additional amount of compensation or extension of time is based on provisions of the Contract or on an alleged breach of the Contract. Each supporting or breached Contract provision, and a statement of the reasons why each such provision supports the claim, must be specifically identified or explained.

(c) Excerpts from manuals or other texts which are standard in the industry, if available, that support the Contractor’s claim.

(d) The details of the circumstances that gave rise to the claim. (e) The date(s) on which any and all events resulting in the claim occurred, and the date(s)

on which conditions resulting in the claim first became evident to the Contractor. (f) Specific identification of any pertinent document, and detailed description of the

substance of any material oral communication, relating to the substance of such claim. (g) If an extension of time is sought, the specific dates and number of days for which it is

sought, and the basis or bases for the extension sought. A critical path method, bar chart, or other type of graphical schedule that supports the extension must be submitted.

(h) When submitting any claim over $50,000, the Contractor shall certify in writing, under oath and in accordance with the formalities required by the contract, as to the following: (1) That supporting data is accurate and complete to the Contractors best knowledge and belief; (2) That the amount of the dispute and the dispute itself accurately reflects what the Contractor in

good faith believes to be the Departments liability; (3) The certification shall be executed by:

a. If the Contractor is an individual, the certification shall be executed by that individual. b. If the Contractor is not an individual, the certification shall be executed by a senior

company official in charge at the Contractor’s plant or location involved or an officer or general partner of the Contractor having overall responsibility for the conduct of the Contractors affairs.

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CONTROL OF WORK

The undersigned is duly authorized to certifY this claim onbehalf of (the Contractor).

(The Contractor) certifies that this claim is made in goodfaith, that the supporting data are accurate and complete tothe best of the Contractor s knowledge and belief, and thatthe amount requested accurately reflects the Contractadjustment for which (the Contractor) believes that theDepartment is liable.

(THE CONTRACTOR)

By: _

(Name)(Title)

Date ofExecution: _

105

The Contractor agrees to follow the procedure described in this Section and that any claimeddollar amount and/or relief sought, not made pursuant to this Section, within the time limits prescribedshall be forever waived and not raised at any subsequent meeting or hearing dealing with the claim. TheDepartment shall establish a claims procedure to be followed, consistent with these Specifications, whichclaims procedure shall provide the means and methods by which the Contractor and the Department shallprocess the claim.

Claims and disputes submitted in accordance with this Section, will be first reviewed fully at theDistrict level. Within 30 calendar days after receiving the claim submittal, the District Engineer willrespond, in writing, with the District's decision. If additional time is required by the District to reviewthe claim, the District Engineer will notify the Contractor. Rejection of the claim or dispute by theDistrict may be appealed to the Claims Committee for review. The Contractor shall give notice of theappeal, in writing, within ten calendar days of the rejection by the District Engineer. The ClaimsCommittee will conduct a claim review meeting attended by representatives of the Contractor and theDistrict. The Committee will conduct the claims review meeting within 45 calendar days after receivingthe Contractor's notice of appeal. The proceedings of the Claims Hearing will be recorded by a CourtReporter. The cost associated with the Court Reporter will be shared equally by the Department and theContractor. A copy of the record of the Claims Hearing will be made available to the Contractor.

Within 15 calendar days of the Hearing, the Committee's Chairperson will notify the Contractor,in writing, of the Committee's decision.

The Contractor may appeal the Claims Committee's decision to the Chief Engineer of theDepartment requesting to proceed with the arbitration process as outlined in Subsection 105.17. TheContractor shall give notice of the appeal to the Claims Committee's Chairperson, in writing, within tencalendar days after receiving the Claims Committee's decision.

105.16 Chief Engineer's Decision. After receiving the written notification from the Contractor,appealing the Claims Committee's decision and requesting an Arbitration hearing as outlined inSubsection 105.17, the Chief Engineer will notify the Contractor, in writing, within 30 calendar days of

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District of Columbia DOT Standard Specification language Section 103 Article 7, Disputes Claim Certification is under #5 below: (a) All claims by a Contractor against the District arising under or relating to a contract shall be in writing and shall be submitted to the Contracting Officer for a decision. The Contractor’s claim shall include at least the following: (1) A description of the claim and the amount in dispute. (2) Any data or other information to support the claim. (3) A brief description of the Contractor’s efforts to resolve the dispute prior to filing the claim, and (4) The Contractor’s request for relief or other action by the Contracting Officer. (5) Certification that, to the best of the Contractor’s knowledge, the cost and pricing data included with the claim is accurate, complete and current as of the date of claim submission. The Contractor shall agree that there is a continuing requirement to update cost and pricing data through the date of negotiations with the District are completed. The Contractor shall also agree that prices, including profit or fee, will be adjusted to exclude any significant price increases occurring as a result of cost or pricing data that was inaccurate, incomplete or not current.

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CERTIFICATE OF CLAIM No. _ __

PROJECT NO. COUNTY CONTRACTOR __ Personally appeared before the undersigned, an officer duly authorized by law to administer oaths, _ hereby certifies under oath (Name and Title of officer) as follows: 1. I am authorized to make this certification on behalf of 2. __ _ ;

(Name of Contractor) 3. I make this Certification of Claim in good faith based upon

my personal knowledge of the matters set forth in the claim; 4. The costs set forth in the claim are accurate and were

actually incurred by ; (Name of Contractor) 5. The contractor has found and demonstrated a cause and effect

relationship between the costs set forth in the claim and some action or inaction on the part of the Georgia Department of Transportation, and that the supportive data of the cause and effect relationship are accurate and complete to __

(Name of Contractor) best knowledge and belief and are set forth and documented in the body of the claim;

6. The amount of the claim accurately reflects what

__ believes to be the (Name of Contractor)

liability of the Georgia Department of Transportation; and 7. I am aware that whoever makes any false statement, false

representation, false report or false claim with respect to the character, quality, quantity, or cost of any work performed or materials furnished in connection with the construction of a Federal-Aid Project shall be fined not more than $10,000 or imprisonment not more than 5 years or both.

_ _____ Name and Title of Officer Sworn to and subscribed before me this __ day of ______ , 20 . __

Notary Public

Idaho Claim Certification (found in Subsection 105.17 of our Standard Specs)

6. The above data shall be accompanied by a notarized statement from the Contractor containing the following certification:

Under penalty of law for perjury or falsification, the undersigned,

___________________________________________

(Name)

___________________________________________

(Title)

___________________________________________

(Company)

hereby certifies that the claim is made in good faith; that the supporting data are accurate and complete to the best of my knowledge and belief; that the amount requested accurately reflects the contract adjustment for which the Contractor believes the Idaho Transportation Department is liable; and that I am duly authorized to certify the claim on behalf of the Contractor.

___________________________________________

(Dated)

Subscribed and sworn before me this _______ day of _____________________, 20 _____.

Notary Seal

My commission expires: _______________________

Art. 109.09 Measurement and Payment

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The Contractor may present a claim made by a Subcontractor founded upon theterms of the contract or the actions and orders of the Engineer without being firstrequired to make payment to the Subcontractor provided: the Contractor makeswritten certification that the Subcontractor is entitled to additional compensation; thatthe Subcontractor will be paid in the event of a favorable resolution of the claim; andthat the subcontract, releases and waivers executed by the Subcontractor do not barpayment to the Subcontractor. The written certification may authorize theSubcontractor to present the Subcontractor claim directly to the Department. If suchauthorization is given, the Contractor need not participate in the verbal presentation ofthe claim. In any event, the submission shall include a copy of the subcontract, andany releases or waivers signed by the Subcontractor in favor of the Contractor. TheContractor’s interest in the Subcontractor’s claim shall not be assigned or otherwisedisposed of except as specified in Article 108.01.

(a) Submission of Claim. All claims filed by the Contractor shall be in writingand in sufficient detail to enable the Department to ascertain the basis andamount of the claim. All claims shall be submitted to the District Engineer.As a minimum, the following information must accompany each claimsubmitted:

(1) A detailed factual statement of the claim for additional compensationand time, if any, providing all necessary dates, locations, and items ofwork affected by the claim.

(2) The name of any State official or employee involved in orknowledgeable about the claim.

(3) The specific provisions of the contract which support the claim and astatement of the reasons why such provisions support the claim.

(4) If the claim relates to a decision of the Engineer which the contractleaves to the Engineer’s discretion or as to which the contract providesthat the Engineer’s decision is final, the Contractor shall set out in detailall facts supporting his/her position relating to the decision of theEngineer.

(5) The identification of any documents and the substance of any oralcommunications that support the claim.

(6) Copies of any identified documents, other than State documents anddocuments previously furnished to the State by the Contractor, thatsupport the claim (manuals which are standard to the industry, used bythe Contractor, may be included by reference).

(7) If an extension of time is sought, the specific days and dates for which itis sought, the specific reasons the Contractor believes a time extensionshould be granted, and the specific provisions of Section 108 underwhich it is sought.

(8) If additional compensation is sought, the exact amount sought and abreakdown of that amount into direct labor, direct materials, directequipment, direct jobsite overhead, and direct offsite overhead.

(9) A statement containing the following language:

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Measurement and Payment Art. 109.09

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Under penalty of law for perjury or falsification, the undersigned,

_________________,____________________,of _________________,(name) (title) (company)

hereby certifies that the claim for compensation and time, if any, madeherein for work on this contract is a true statement, fully documentedand supported under the contract between the parties.

Dated ___________________________/S/_______________________

Subscribed and sworn before me this _____ dayof__________________

_____________________________

Notary PublicMy Commission Expires________________________________________

(b) Record Retention. It is the responsibility of the Contractor to keep full andcomplete records of the costs and additional time incurred for any claim.The Contractor shall permit the Department to have access to those recordsand any other records as may be required by the Department to determinethe facts or contentions involved in the claim. The Contractor shall retainthose records according to Article 109.10.

(c) Audit. All claims filed against the State shall be subject to audit at any timefollowing the filing of the claim. The audit may be performed by employeesof the State or by an auditor under contract with the State. The audit maybegin at any time during the life of the contract, or on 20 calendar daysnotice to the Contractor or its agents if an audit is to be commenced morethan 60 calendar days after the final payment date of the contract. TheContractor, subcontractors or agents shall provide adequate facilitiesacceptable to the Department, for the audit during normal business hours.Failure of the Contractor or its agents to maintain and retain sufficientrecords to allow the auditors to verify all or any portion of the claim or topermit the auditor access to the books and records of the Contractor,subcontractors or agents shall constitute a waiver of the claim and may barany recovery of all or any portion thereunder.

The records subject to retention and audit are all books and recordsincluding but not limited to the following documents:

(1) Daily time sheets and supervisor’s daily reports.

(2) Union agreements.

(3) Payroll records including tax, insurance, welfare, and benefits records.

(4) Material invoices and requisitions.

(5) Material cost distribution worksheet.

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i. A detailed factual statement supporting the Contractor’s contention that the Department’s decision was a breach of contract if the claim is related to a decision that the contract leaves to the Department as discretionary or final.

j. The specific amount and basis of costs sought broken down in the categories specified for force account in 109.05, including a separate calculation of markup as allowed in 109.05.

k. The specific amount of contract time extension sought and the basis for the request, including approved and as-built bar chart 660or critical path method schedules depicting the affected work.

l. A notarized statement, signed by an officer of the Contractor, under the penalties of perjury, that the claim is made in good faith, that no portion of the claim has previously been paid and that the amount of the claim and the supporting documents are true, accurate, and reflect what the Contractor believes to be the Department’s liability.

The Engineer will provide a written notice to the Contractor of receipt of a claim. If the information provided by the Contractor with a claim does not contain 670sufficient detail to enable the Engineer to determine the basis and amount of the claim, the Engineer will notify the Contractor in writing of the specific details required. The Contractor shall provide the required details within 14 days, or other time as mutually agreed, of receipt of the Engineer’s request. If the Contractor fails to provide the requested details within the time frame, the Engineer’s original remedy for the changed condition will be the final determination by the Department and the Contractor shall waive any further right to contest the remedy.

2. Auditing of Claims Claims filed by the Contractor against the Department shall be subject to audit at 680any time following the filing of such claim, whether or not such claim is part of a suit in the courts of the State. The audit may begin a minimum of 30 days after written notice to the Contractor, subcontractor, or supplier and may be extended as mutually agreed by all parties. The Contractor, subcontractor, or supplier shall make a good faith effort to cooperate with the auditors. Failure to cooperate shall constitute a waiver by the Contractor of the claim in its entirety. Failure of the Contractor, subcontractor, or supplier to maintain and retain sufficient records to allow the Department’s auditor to verify the claim shall constitute a waiver of that portion of the claim that cannot be verified and shall bar recovery.

690 (c) Claim Resolution Process

1. Project Level Review The Contractor shall submit the claim to the Engineer at the project level. The

Engineer will review the claim and make an effort to resolve the claim at the project level within 30 days of receipt of the claim, or other time as mutually agreed. Meetings may be requested by either the Engineer or the Contractor to discuss the

105.16

i. A detailed factual statement supporting the Contractor’s pp gcontention that the Department’s decision was a breach of pcontract if the claim is related to a decision that the contract leaves to the Department as discretionary or final.p y

j. The specific amount and basis of costs sought broken down in p gthe categories specified for force account in 109.05, including a g p ,separate calculation of markup as allowed in 109.05. p p

k. The specific amount of contract time extension sought and the p gbasis for the request, including approved and as-built bar chart q , g ppor critical path method schedules depicting the affected work. p p g

l. A notarized statement, signed by an officer of the Contractor,, g y ,under the penalties of perjury, that the claim is made in good p p j y, gfaith, that no portion of the claim has previously been paid and , p p y pthat the amount of the claim and the supporting documents are pp gtrue, accurate, and reflect what the Contractor believes to be the, ,Department’s liability.

The Engineer will provide a written notice to the Contractor of receipt of ag p pclaim. If the information provided by the Contractor with a claim does not containp ysufficient detail to enable the Engineer to determine the basis and amount of thegclaim, the Engineer will notify the Contractor in writing of the specific details, g y g prequired. The Contractor shall provide the required details within 14 days, or other q p q y ,time as mutually agreed, of receipt of the Engineer’s request. If the Contractor fails y g , p g qto provide the requested details within the time frame, the Engineer’s original p q , g gremedy for the changed condition will be the final determination by the Departmenty g yand the Contractor shall waive any further right to contest the remedy.

2. Auditing of ClaimsgClaims filed by the Contractor against the Department shall be subject to audit at y g p j

any time following the filing of such claim, whether or not such claim is part of a y g g , psuit in the courts of the State. The audit may begin a minimum of 30 days after y g ywritten notice to the Contractor, subcontractor, or supplier and may be extended as, , pp ymutually agreed by all parties. The Contractor, subcontractor, or supplier shall makey g y p , , ppa good faith effort to cooperate with the auditors. Failure to cooperate shall constituteaag p pa waiver by the Contractor of the claim in its entirety. Failure of the Contractor, y y ,subcontractor, or supplier to maintain and retain sufficient records to allow the, ppDepartment’s auditor to verify the claim shall constitute a waiver of that portion of p ythe claim that cannot be verified and shall bar recovery.

(c) Claim Resolution Process

1. Project Level Review jThe Contractor shall submit the claim to the Engineer at the project level. Theg p j

Engineer will review the claim and make an effort to resolve the claim at the project g p jlevel within 30 days of receipt of the claim, or other time as mutually agreed.y p , y gMeetings may be requested by either the Engineer or the Contractor to discuss the

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GP-5.14 FILING OF CLAIM BY CONTRACTOR Unless a shorter period is prescribed by law or elsewhere in this Contract,

(a) The Contractor shall file a written notice of claim for extension of time, equitable adjustment, extra compensation, damages, or any other matter (whether under or relating to this Contract) with the procurement officer within 30 days after the basis for the claim is known or should have been known, whichever is earlier.

(b) Contemporaneously with or within 90 days of the filing of a notice of a claim, but no later than the date that final payment is made, a Contractor shall submit the claim to the appropriate procurement officer. The claim shall be in writing and shall contain: (1) An explanation of the claim, including reference to all Contract provisions upon

which it is based; (2) The amount of the claim; (3) The facts upon which the claim is based; (4) All pertinent data and correspondence that the Contractor relies upon to

substantiate the claim; and (5) A certification by a senior official, officer, or general partner of the Contractor or

subcontractor, as applicable, that, to the best of the person’s knowledge and belief, the claim is made in good faith, supporting data are accurate and complete, and the amount requested accurately reflects the Contract adjustment for which the person believes the Administration is liable.

(c) The claim shall also contain itemized supporting data for the elements of cost the Contractor claims to have incurred or it will incur. This data shall be in sufficient detail to permit analysis by the Administration of material, labor, equipment, subcontract and overhead costs as well as profit and shall include all work covered by the claim, whether deleted, added, or changed. Subcontract cost shall be supported by similar detailed data.

(d) A notice of claim or a claim that is not filed within the prescribed time shall be dismissed.

GP-5.15 DISPUTES (a) This Contract is subject to the provisions of Title 15, Subtitle 2, State Finance and

Procurement Article (Dispute Resolution) of the Annotated Code of Maryland and COMAR 21.10 (Administrative and Civil Remedies).

(b) Except as otherwise may be provided by law, all disputes arising under or as a result of a breach of this Contract that are not disposed of by mutual agreement shall be resolved in accordance with this clause.

(c) As used herein, “claim” means a written demand or assertion by one of the parties seeking, as a legal right, the payment of money, adjustment or interpretation of Contract terms, or other relief, arising under or relating to this Contract. A voucher, invoice, or request for payment that is not in dispute when submitted is not a claim under this clause. However, if the submission subsequently is not acted upon in a reasonable time, or is disputed either as to liability or amount, it may be converted to a claim, for the purpose of this clause.

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(d) A claim shall be made in writing and submitted to the procurement officer for decision in consultation with the Office of the Attorney General.

(e) When a claim cannot be resolved by mutual agreement, the Contractor shall submit a written request for final decision to the procurement officer. The written request shall set forth all the facts surrounding the controversy.

(f) The Contractor, at the discretion of the procurement officer, may be afforded an opportunity to be heard and to offer evidence in support of the claim.

(g) The procurement officer shall render a written decision on all claims within 180 days of receipt of the Contractor’s written claim, unless the time is extended by mutual agreement of the parties. If a decision is not issued within 180 days, the procurement officer shall notify the Contractor of the time within which a decision shall be rendered and the reasons for such time extension. The decision shall be furnished to the Contractor, by certified mail, return receipt requested, or by any other method that provides evidence of receipt. The procurement officer’s decision shall be deemed the final action of the State.

(h) The procurement officer’s decision shall be final and conclusive unless the Contractor mails or otherwise files a written appeal with the Maryland State Board of Contract Appeals within 30 days of receipt of the decision.

(i) Pending resolution of a claim, the Contractor shall proceed diligently with the performance of the Contract in accordance with the procurement officer’s decision.

D:\Claims\Survey\Certifications\Updated certifications 7-29-09\Massachusetts Claim Certification.doc

XYZ CONTRACTORS, INC Letterhead

123 Main Street – Boston, MA 12345 Phone / Fax

E-Mail Address

Contract #54321 Route 100 Bridge Replacement Springfield / District 2 CERTIFICATION OF CLAIM Claim No. 1-54321-001 Schedule Delay / Additional Scope Amount = $ 99,999.99 As out lined in Subsection 7.16 of the Massachusetts Highway Department Standard Specifications for Highways and Bridges (1988), it is certified that the information provided for the above noted claim represents additional costs incurred, other than as provided for in the contract, during the performance of work under the referenced contract. The costs as shown are an amount we believe to be a fair and equitable amount, legally due for the performance of the work for which payment is being claimed. _____________________________________ John Q. Smith Vice President / Project Manager XYZ Contractors, Inc. Sworn to and subscribed before me by John Q. Smith who is personally known to me this 1st day of July, 2000. ________________________________ My commission expires December 31, 2002. Mary X. Jones, Notary Public

Michigan Department of Transportation

1953 (01/08) CLAIM CONTENT AND CERTIFICATION

(Tab from field to field)

CONTROL SECTION AND JOB NUMBER TODAY’S DATE

PRIME CONTRACTOR

SUBCONTRACTOR

CONTRACT AMOUNT CONTRACT AWARD DATE DELIVERY ENGINEER

Claim Content – Attach the Following: A. A concise description of the circumstances why the contractor is entitled to the claim, including dates,

locations, items of work, and actions or conditions that caused the claim. B. A clear contractual basis for the claim, to include reference to the appropriate standard specification,

plan sheet, special provision, and contract document. C. A complete breakdown of the costs associated with the claim, as follows:

• Documented additional job site labor expenses. • Documented additional cost of materials and supplies. • A list of additional equipment costs claimed, including each piece of equipment and the rental

rated claimed for each. • Any other additional direct costs or damages, and the documents to support the costs.

D. A concise description of the impact of the claim to the progress schedule. E. For a claim related to an extension of time, include a detailed compilation of:

• Specific dates and the exact number of calendar or work days sought for the time extension. • The basis for entitlement to time for each day. • All documentation of the delay. • All impacts of the delay to the progress schedule/critical path.

An individual or contractor who knowingly certifies false information may be subject to prosecution. The undersigned is duly authorized to certify this claim on behalf of ___________________________ (the Contractor). ___________________________ (the Contractor) certifies that this claim is made in good faith, that the supporting data are accurate and complete to the best of our knowledge and belief, and the amount requested accurately reflects the contract adjustment for which ___________________________ (the Contractor) believes the department is liable. THE CONTRACTOR

TYPE/PRINT NAME AND TITLE

SIGNATURE DATE OF EXECUTION

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Notification of a claim or the Engineer's account of the costsinvolved will not in any way prove or substantiate the validity of aclaim. If, upon the Department's consideration of a claim, additionalcompensation is found to be due, it will be allowed and paid for asExtra Work.A Claim Submittals

Claim submittals shall be in sufficient detail to enable the Engineerto determine the basis for entitlement and the resulting costs. Thefollowing minimum information mustaccompany each claim submitted:

1. Detailed factual statement ofthe claim providing-all necessarydates, locations, and items ofwork affected by the claim.

2. The date actions resulting in the claim occurred or conditionsresulting in the claim became evident.

3. A copy of the "Notice of Potential Claim", filed by theContractor for the specific claim.

4. The name, title, and activity of each Department employeeknowledgeable about facts that gave rise to such claim.

5. The name, title, and activity of each Contractor employeeknowledgeable about facts that gave rise to such claim.

6. The speCific provisions ofthe Contract that support the claim,and a statement why the provisions support the claim.

7. The identification of any pertinent documents,and thesubstance of any material oral communication relating to theclaim. -

8. A statement whether the additional compensation or extensionoftime is based on the provisions ofthe Contract or an allegedbreach of Contract.

9. If an extension of time is also sought, the specific days forwhich it is sought and the basis for such claim as determinedby an analysis of the construction schedule.

10. The amount of additional compensation sought and abreakdown ofthe amount.

B Required Certification of ClaimsThe claim submittal shall include the Contractor's written

certification, under oath, attesting to the following:. 1. The claim is made in good faith.2. Supp~rtive data is accurate and complete to the Contractor's

best knowledge and belief.3. The amount of the claim accurately reflects the Contractor's

actual cost incurred.In complying with this requirement, the Contractor's claim must

include the following fully executed certification:

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1517

Under the penalty of law for perjury or falsification, theundersigned,

(Name)______~ of

(Title)

(Company)hereby c.ertifies that the claim for extra compensation and time, if

any, made herein for work on this Contract is a true statement of theactual costs incurred and time sought, and is fully documented andsupported under the Contract between the parties.Dated lsi-----------'---Subscribed and sworn before me this __' day of__,20_.Notary Public --'-_-,- _My commission Expires _C Review of Claims

All claims filed will be subject to review by the department at anytime, following the claim filing, whether or not the claim is part ofa suitpending in the courts of this State. The review may begin on 10calendar days written notice. The Contractor, Subcontractor(s), orSupplier(s) shall cooperate with the Department and shall provide at aminimum, access to the following documents:

1. Daily time sheets and foreman's daily reports.2. Union agreements, ifany.3. Insurance, welfare, and benefits records.4. PayroU register.5. Earnings records.6. Payroll tax returns.7. Material invoices, purchase orders, and all material and

supply requisition Contracts.8. Material cost distribution worksheets.9. Equipment records (list of company equipment, rates, etc.).10. Vendor rental agreements, and subcontractor invoices.11. Subcontractor payment certificates. '12. Canceled checks (payroll and vendors).13. Job cost report.14. Job payroInedger.15. General ledger, general journal, (if used) and all subsidiary

ledgers and jou!TIals together with all supportingdocumentation pertinent to entries made in these ledgers andjournals.

16. Cash disbursements journal.

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--------- ---------'- --- ------ ----

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CSD-155 07/14/2004

MDOT NOTICE OF CLAIM FORM

This form is required to be submitted as per Subsection 105.17 - Claims for Adjustments and Disputes to file a notice of claim for additional compensation and/or time.

Project Number: County: Route & Termini: Date Claim was Submitted: Claim Number: Type of Claim: Date and Time (AM, PM) of Event: Location of Event: Specific Subsection(s) of Contract Addressing Event: Description of Event: Describe How the Event Impacted the Project (current & future): Describe Requested Compensation: Attach any additional sheets as necessary to complete the form and attach auditable documentation for additional compensation requests. I certify that the foregoing statements made by me are true. I am aware that if any statement made herein is willfully false or fraudulent, that I am subject to punishment by law. I further certify that I have made a good faith effort to disclose the full nature and extent of this claim. COMPANY NAME POSITION SIGNATURE OF CLAIMANT’S AUTHORIZED REPRESENTATIVE Instructions: Each claim submitted on a project should be sequentially numbered.

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105.16.8 Required Certification of Claims. The claim submittal shall include the contractor's written certification, under oath, attesting to the following: (a) The claim is made in good faith. (b) Supporting data is accurate and complete to the contractor's best knowledge and belief. (c) The amount requested includes all costs related to the specific claim and that no additional related claims will be submitted. (d) The amount of the claim accurately reflects the contractor's actual cost incurred. To comply with this requirement, the contractor shall file a notarized statement with the claim, in which the statement includes at least the following: AFFIDAVIT FOR CLAIM State of (__________________________________) County of (________________________________) (Name of the Person Making this Affidavit), the (State Your Title or Position in the Firm) [hereinafter "the Affiant"], of (State the Name of the Firm Submitting the Claim), [hereinafter "the Claimant"], being first duly sworn upon his or her oath, states as follows: 1. This Affidavit is made upon the personal knowledge of the Affiant, and is authorized by the Claimant to be made in behalf of the Claimant. 2. The Claim being submitted by the Claimant to the Missouri Highways and Transportation Commission at this time on (Route), (County), (Job No.), is made in good faith. The Affiant has the requisite knowledge of the Claim, and the facts and supporting data, to be able to make this Affidavit and accurately attest to the facts herein. 3. The amount requested includes all costs related to the claim or controversy and that no additional claim will be submitted. 4. All documents, records, charts, schedules, computer programs and printouts, and other data of any nature or description, which are submitted in support of this Claim pursuant to Sec 105.16.7 of the Missouri Standard Specifications for Highway Construction are accurate and complete in all respects, to the best knowledge and belief of the Affiant and the Claimant. 5. Under all applicable penalties of state or federal law for perjury, submitting a false affidavit or statement, fraud, stealing or other falsification, the Affiant hereby certifies that this Claim for extra compensation and time, if any, submitted herewith by the Claimant for work performed on this contract, is a true and accurate statement of the Claimant's actual costs incurred and time sought in performing the contract work, and is fully documented and supported under and pursuant to the contract described above between the Claimant and the Missouri Highways and Transportation Commission. 6. This Affidavit is given in compliance with Sec 105.16 of the Missouri Standard Specifications for Highway Construction, which forms a part of that contract. __________________________________________________ (Type or Print Name of the Claimant) By:_______________________________________________ (Affiant's Legal Signature) Subscribed and sworn to before me, a notary public, on this day of , (year). __________________________________________________ Notary Public My commission expires: ______________________________________________ 105.16.8.1 The person signing the claim and affidavit under oath shall be the owner if the contractor is a sole proprietorship, shall be a general partner if the contractor is a partnership, shall be an authorized agent if the contractor is a limited liability company or joint venture, or shall be an authorized officer or member of the board if the contractor is a corporation. 105.16.8.2 No claim shall be deemed filed under the contract by a contractor until: (a) Every item of information provided for in Sec 105.16.7 has been provided or the contractor makes an affirmative, unequivocal statement as part of its claim that no record, document or information provided for by a specific provision of that section exists, and (b) The sworn certification precisely as set forth in Sec 105.16.8 has been made and delivered to the Secretary of Commission.

CSB105_16_2 (5-7-09)

CERTIFIED CLAIM MONTANA DEPARTMENT OF TRANSPORTATION

CERTIFICATION OF EACH PART OF A CLAIM IS AN ABSOLUTE PREREQUISITE TO A CLAIM BEING CONSIDERED BY THE DEPARTMENT

DO NOT ALTER THE LANGUAGE OF THIS FORM! _________________________________________ ________________________________ PROJECT NAME PROJECT NUMBER Anyone knowingly presenting a claim, any part of which is found to be false or fraudulent, is subject to the criminal penalties of §45-7-210, MCA, and civil liabilities of §17-8-403, MCA, in addition to criminal and civil penalties applicable under Federal law. The Contractor understands and agrees that, under its contract with the Department, it must certify any claim. Failure to fully certify the claim as required herein is a failure to utilize the Department's procedure for dispute settlement, and bars further administrative or judicial review of the claim. Understanding the above, and with the intent to obtain the claimed amount from the State, the Contractor by the undersigned certifies that: a this claim is made in good faith; b the Contractor has fully reviewed the claim and its supporting data, including its project

records (and the project records of any Subcontractor work associated with the Contractor’s claim) to ensure that any personnel and equipment items listed in the claim are properly included;

c the supporting data are accurate and complete to the best of the Contractor's knowledge and belief, and support that all personnel and equipment items listed in the claim are properly included;

d no part of the claim is false or fraudulent; and, e the amount requested, as shown on the attached pages, accurately reflects the contract

adjustment for which the Contractor believes the State is liable, and is a complete statement of the claim.

_________________________________ By: ___________________________________ Name of Contractor Contractor's Representative _________________________________ ___________________________________ Date Representative's Title

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CSB105_16_2 (5-7-09)

TO: ___________________________ , Project Manager Montana Department of Transportation Date of Notice of Claim (reference 105.16.1): _______________ Project Name: ___________________________ No: ______________________ A notice is required for each separate claim that may be filed (only one claimed condition or event per Notice). Attach additional pages if required. In accordance with Subsection 105.16, notice is hereby given of the following claim for additional compensation, additional time, etc., for this Project: 1. Statement of Claim. (State the basis for the claim.) 2. Conditions. (Fully describe the physical condition, Project Manager’s orders, directives or

actions, or other conditions that directly contribute to the claimed problem.)

3. Date of Contractor’s Discovery of the above-stated Condition: ______________

Explain and include all documentation showing the progression and history of the disagreement into a claim, including correspondences._______________________

_____________________________________________________________________________ 4. Plans and Specifications. (Fully describe the specifications that are in conflict or are unclear or ambiguous; or the conflicts or errors in the plans that are related to the claimed problem.) 5. Other Condition or Occurrence. (Describe fully.) The following portions of work and operations will be affected (attach pages if needed):

CSB105_16_2 (5-7-09)

1. Portions of work. (Fully describe the contract items, and locations by station or structure.) 2. Operations. (Fully describe specific operations that will be affected for each location involved. Immediately submit a revised operation schedule showing the impact on the activities.) Contractor’s objections are: (State in detail the specific objections to performing work for the compensation stated in the contract, or within the time required, or other objections.) The Contractor believes the nature and amount of the adjustment in compensation or extension of time that is due or may be due is as follows: (Describe fully and specifically.) ____________________________________ _____________________________ Signature & Date Title ____________________________ _____________________________________ Contractor Submitting the Notice Contractor Superintendent & Date Only claims from the Contractor will be accepted. The Notice may not be submitted by a Subcontractor. The Contractor cannot pass a Subcontractor’s claim through to the Department. Note:

Use of a downloaded form is deemed an agreement by the user that the form will be used exactly as-is. Do not alter the form in any way as the Department's specifications and procedures rely upon the language of the standard forms. If a submitted form is altered in any way, the form will be rejected and it will be a breach of contract. The alteration may be brought to the attention of the Transportation Commission.

Required Certification Of Claims. The claim submittal shall include the Contractor's written certification,

under oath, attesting to the following: 1. The claim is made in good faith. 2. Supportive data is accurate and complete to the Contractor's best

knowledge and belief. 3. The amount of the claim accurately reflects the Contractor's actual cost

incurred. In complying with this requirement, the Contractor shall use the following

form.

CERTIFICATE OF CLAIM

Under the penalty of law for perjury or falsification, the undersigned, ______________________________ , ______________________________ (Title) of _________________________________ (Company) hereby certifies that the claim for extra compensation and time made herein for work on the Contract is a true statement of the actual costs incurred and time sought, and is fully documented and supported under the Contract between the parties.

_______________ ___________________________

(Date) (Signature)

Notarized

F. Required Certification of Disputes Over $50,000. When submitting any dispute over $50,000, the Contractor shall certify in writing, under oath and in accordance with the formalities required by the contract, as to the following:

1. That supporting data is accurate and complete to the Contractor=s best knowledge and belief; 2. That the amount of the dispute and the dispute itself accurately reflects what the Contractor in good faith believes to be the Department=s liability; 3. The certification shall be executed by:

a. If the Contractor is an individual, the certification shall be executed by that individual. b. If the Contractor is not an individual, the certification shall be executed by a senior company official in charge at the Contractor=s plant or location involved or an officer or general partner of the Contractor having overall responsibility for the conduct of the Contractor=s affairs.

Form CCSF (9-28-07) Page 1 of 4

North Carolina Department of Transportation Contractor Claim Submittal Form

Contract No.: Division: TIP No.: County: Project No.: Contractor: Date: Resident Engineer:

The Request is for: An Extension in Contract Time: Amount: Days An Extension in Intermediate Contract Time No. For: Days Hours Additional Compensation Amount: $ ___________________

Contractor Claim Submittal Form Instructions

1. Complete the requested project information on page 1. 2. Complete the applicable specification section(s) on pages 2-4. For contract time extension requests,

complete the applicable section on page 2. For requests for additional compensation, complete the applicable section(s) on pages 3-4.

3. Attach supporting documentation (i.e. cost records, weekly records, supporting data and information). 4. Complete the certification section on page 1. Note: The Contractor’s Authorized Representative should

be someone who has the authority to sign supplemental agreements for the Contractor. 5. Forward the original form and supporting information to the Resident Engineer if the claim is an active

claim. If the claim is a final claim, forward the original form and supporting information to the State Construction Engineer.

Contractor’s Certification

I hereby certify that the information contained herein is submitted in accordance with the Standard Specifications and is true and accurate.

_____________________________________ _______________________________ Signature Title

____________________________________ _______________________________ (Print or Type Signer’s Name) Date

Comments ______________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

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Contractor Claim Submittal Form


Requests for Extensions in Contract Time: (Applicable section(s) to be completed by Contractor)

108-10(B)3 Delays To The Contractor’s Controlling Operation(s)

1. What is the alleged controlling operation delayed? _____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What are the circumstances resulting in the alleged delay? ______________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. What calendar dates/times was the controlling operation allegedly delayed? ________________through___________________

108-10(B)4 Changes In The Work Ordered By The Engineer (Additional Work, Etc.)

1. What is the category of the request? Reduction in Quantities Elimination of Items Additional Work Extra Work

2. What is the affected operation? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________

3. What is the controlling operation? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. What are the calendar dates/times affected? ______________________________through_______________________________ 5. What time extension is being requested? ______________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Requests for Additional Compensation: (Applicable section(s) to be completed by Contractor)

104-3 Alterations of Plans or Details of Construction

1. Was the Engineer notified in writing prior to performing the work? Yes No Date of Notification: _________________ 2. Is the claim and supporting documentation being submitted within 120 days after completion of the work? Yes No 3. Have weekly records of the alleged alteration been submitted as requested by Subarticle 104-8(B)? Yes No 4. Has the Character of performing the work materially changed? Yes No Please explain: _____________________

______________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Has the cost of performing the work changed? Yes No Please explain: __________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

104-4 Suspension of Work 1. (a) Was the temporary suspension ordered by the Resident Engineer in writing? Yes No If no, go to (b). If yes:

What are the dates of authorized temporary suspension: __________________________through______________________ Was the Engineer notified in writing within 7 days of the suspension of the intent to file a claim for additional compensation?

Yes No Date of Notification: _____________________ Is the request for adjustment in compensation with cost records, supporting data and information being submitted within 14 calendar days of the receipt of the notice to resume work? Yes No Go to 2.

(b) What was the alleged suspension? ________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What are the dates of the alleged suspension: _____________________________through___________________________

Was the Engineer notified in writing of the intent to file a claim for additional compensation due to the alleged suspension? Yes No Date of Notification: _____________________________________________________________

Is this request for adjustment in compensation with cost records, supporting data and information being submitted within 14 calendar days after the last day of the alleged suspension of work? Yes No Go to 2.

2. Have weekly records of the suspension or alleged suspension been submitted as required by Subarticle 104-8(C)? Yes No 3. Was the temporary suspension or alleged suspension more than 24 hours in duration? Yes No



Requests for Additional Compensation: (Cont’d) (Applicable section(s) to be completed by Contractor)

104-7 Extra Work 1. Was the Engineer notified in writing prior to performing the work? Yes No Date: ______________________________ 2. Is the claim being submitted within 120 days after completion of the work? Yes No 3. Have weekly records of the alleged extra work been submitted as required by Subarticle 104-8(B)? Yes No 4. What was the alleged extra work? ___________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

105-11 Inspection of Work 1. Were cost records of the inspection kept in accordance with Article 109-3 (Force Account Work)? Yes No 2. Did the Engineer determine the inspected work to be acceptable? Yes No If no, explain: ________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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104.05

No Contract adjustment will be allowed under this section to the extent that perform-ancewouldhavebeen suspendedor delayedbyanyother cause, or forwhichanadjust-ment is provided for or excluded under any other term or condition of this Contract.

TheContractor’swritten notice of intent to file a claim, followedby the claim for extracompensation for suspensionordelayofworkshall beasper the requirementsoutlinedinSection 104.06, except that the requirednotice time framewill be as specified in thisSection.

104.06 CLAIM FOR EXTRA COMPENSATION.

A. Notice of Intent to File a Claim. If theContractorcontends thatadditionalcom-pensation is due for work or material not clearly covered in the Contract, theContractor shall promptly notify the Engineer in writing of the intention to file aclaim and the basis for additional compensation before beginning or continuingconstruction on the affected work. If the basis for the claim does not become ap-parent until after proceeding with the work and it is not feasible to stop the work,the Contractor shall immediately notify the Engineer that work is continuing andthat written notification of the intent to file a claim will be submitted withinten calendar days. The failure to give the required notification or to provide theEngineer proper facilities and assistance in keeping strict account of actual costswill constitute a waiver of the claim for additional compensation in connectionwith thework already performed.Notification of a claim, and the fact that theEn-gineer has kept account of the costs involved, shall not be construed as proving orsubstantiating the claim’s validity.

Noticemust be provided on theDepartment formentitled “Notice of Intent to Filea Claim.”

TheContractor shallmail the original notice to the Project Engineer and a copy tothe Construction Engineer.

TheContractor shall define each basis for which additional compensationwill besought. Failure to properly supply all of the information requiredon the formenti-tled “Notice of Intent to File a Claim” shall constitute a waiver of the right to re-cover additional compensation for claim items not identified.

B. Submission of the Claim.All claims shall be submitted in writing not later than90 daysafter the final estimatehasbeensubmitted to theContractor, asoutlined inTitle 24 of the North Dakota Century Code.

If theContractor signs the final payment statement and certifies that the quantitiesare a true and correct statement of thework performed, the Contractor, by this ac-tion, accepts the amount stated as full and final payment on the Contract for thestated Project and waives all rights to any additional payments to complete theProject.

The claim submittal must describe and detail all claim items being submitted forreview as described in the notice of intent to file a claim in 104.06 A. Sec-tion 109.04 shall not be used for costing of claims submitted. The description anddetail in the claim submittal shall, at a minimum include:

1. A detailed narrative justification citing the basis for the claimwith referenceto relative portionsof thePlans, Specifications, or otherContract documents.

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104.06 B.2.d.(4)

2. A detailed explanation of the amount of extra compensation claimed is re-quired for each item. Total Project cost claims will not be allowed as part ofthe claim submitted. Allowable costs submitted for each of the individualclaim itemswill be verifiedusinggenerally acceptedContract cost principlesand procedures. The only costs which will be allowed will be as follows:

a. Materials purchased as verified by copies of paid invoices.

b. Direct payroll as verified by copies of certified payrolls.

c. Owners share of payroll additives with each employee’s applicable“ceilings” accounted for on the claim itemand verified by applicable ac-counting records.

d. Equipment. No allowance will be made for equipment replacement orreplacement escalators, cost of facilities capital, interest, or anyother ad-ditives not listed. All equipment hours will be paid for as straight time.The only equipment payments that will be made are as follows:

(1) Owned Equipment. Payment for the actual hours of Contractor-owned equipment will be 70 percent of the base rate as determinedusing the procedures outlined in the then current edition of the De-partment manual entitled Rental Rates for Equipment and TrafficControl Devices.

The computed hourly equipment cost times the number of hoursclaimed shall not exceed the Contractor’s actual purchase price forthe piece of equipment being claimed.

Subcontractor-owned equipment will be paid for in the same man-ner as Contractor-owned equipment unless such equipment hasbeen rented, leased, or hired by the Contractor, as provided for in(2) below.

(2) Leased,Rented,orHiredEquipment.Payment for leased, rented,or hiredequipment shall be theactual invoicepaymentplus sales taxas verifiedbypaid invoices signedby the lessor, or by checks issuedby the Contractor. If the lease or rental is weekly, the weekly rateshall be divided by 40 to get an hourly equipment cost for the claim.If the lease or rental ismonthly, themonthly rate shall be divided by176 to get an hourly equipment cost for the claim.

The computed hourly equipment cost, for each individual piece ofequipment, times the number of hours claimed shall not exceed theContractor’s actual lease or rental cost for the time frame claimed.

(3) Operating Costs.Equipmentoperatingcostswillbe theequipmentservice charges as determined using the procedures outlined in thethen current edition of theDepartmentmanual entitledRentalRatesfor Equipment and Traffic Control Devices.

(4) Idle Time.Thenumber ofhoursof equipment use tobepaid forwillonly be the hours that the equipment is operating on the claim item.

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104.06 B.2.d.(4)

No payment will be made for equipment on standby unless thestandby is directed in writing by the Engineer, or the standby isproven to be as the direct result of the Department’s actions or inac-tions. Standby will be paid at 50 percent of the hourly bare rate cal-culated by dividing the monthly rate by 176. The listed weekly,daily, or hourly rates will not be used. Operating costs will not bepaid for hours of idle time.

Payment for standby time will not be made on any day the equip-ment operates for eight ormore hours. For equipment accumulatingless thaneight hoursoperating timeonanynormalworkday, standbypayment will be limited to only that number of hours which, whenadded to the operating time for that day equals eight hours. Standbypayment will not be made in any case on days not normally a workday.

e. Completepayment for overheadshall be10percent andprofit shall be10percent applied to the total of (a) through (c) in Section 104.06 B.2. Su-perintendents and their associated costs will be covered by the 10 percentoverhead item.

3. A statement containing the following language shall also be submitted withthe claim:

Under the penalty of law for perjury or falsification, the undersigned,

,

,

of , hereby certifies

that the claim for extra compensation and time, if any, made herein forwork on this Contract is a true statement of the actual costs incurred andtime sought and is fullydocumentedandsupportedunder theContract be

NAME TITLE

COMPANY

I hereby agree that the Department or its authorized representative shallhave the right to examine and copy all Contractor records, documents,work sheets, payrolls, invoices, depreciation schedules, and other datawhich are pertinent to the justification of the claim and to the substanti-ation of all costs related to the claim.

Date/s/

Subscribed and sworn before me this day of ,20 .

My Commission ExpiresNOTARY PUBLIC

4. TheContractor hereby agrees that theDepartment or its authorized represen-tative shall have the right to examine and copy all Contractor records, docu-

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104.08 B.2

ments,worksheets,payrolls, invoices,depreciationschedules, andotherdatawhicharepertinent to the justificationof theclaimand to the substantiationofall costs related to the claim. If the bid documents used in preparation of thebid are not being held in escrow, the Contractor shall submit the bid docu-mentation with the claim.

Failure of the Contractor to adhere to all of the requirements outlined in Sec-tion 104.06 shall serve as a waiver of claim for additional compensation foreach of the claim items submitted.

C. Department’s Response to Claim. After receipt of a properly submitted claim,written notificationwill be given to theContractor indicating approval, partial ap-proval, or disapproval of the claim for additional compensation as per Title 24 ofthe North Dakota Century Code.

D. Conditions Precedent to Contractor’s Demand for Arbitration. Full com-pliance by the Contractor with Section 104.06 is a Contractual condition prece-dent to the Contractor’s right to demand arbitration.

No right shall exist to demand arbitration against the Department until the condi-tions specified in Section 104 and in Title 24 of the North Dakota Century Codehave been complied with.

104.07 CLAIMS AGAINST CONTRACTOR

The Contractor will be notified in writing when construction-related claims are beingassessed against theContractor. Claims in this category include, but are not limited to:(1) unpaid royalty for material removed from Department-optioned pits and borrowareas; (2)materials, supplies, and services obtained from theDepartment; (3) productsand materials not meeting Specifications; and (4) judgments entered against theContractor.

If the claim is not paid within 30 days after written notification, the amount of theclaim shall be withheld from any Contract payments due, except that judgmentsagainst the Contractor by a court will be immediately assessed.

It is not necessary that the claim and the withheld payment be related to the same Pro-ject or to each other.

104.08 VALUE ENGINEERING INCENTIVE.

A. Value engineering incentive applies to cost reduction proposals initiated and de-veloped by the Contractor for changing the drawings, designs, Specifications, orother requirements of the Contract. It does not apply to any proposal unless it isidentified by theContractor at the timeof submission to theDepartment as a valueengineering incentive proposal.

B. The cost reduction proposals contemplated are those that:

1. Would require a Change Order to the Contract on Department forms; and

2. Would result in savings to the Department by providing less costly items ormethods than those specified in the Contract without impairing essential

Ohio does not have a standard form but requires the Contractor to certify the claim. This is our current language: When submitting the Claim Documentation, the Contractor must certify the claim in writing and under oath. Such certification shall attest to the following: 1. The claim is made in good faith. 2. To the best of the Contractor's knowledge, all data offered to support the claim is accurate and complete. 3. The claim amount accurately reflects the Contractor's actual incurred costs and additional time impacts. This claim certification shall also be notarized pursuant to the laws of the State of Ohio. The following is an example of the correct form for a claim certification: (The Contractor) certifies that this claim is made in good faith, that all supporting data is accurate and complete to the best of (the Contractor's) knowledge and belief, and that the claim amount accurately reflects the contract amendment for which (the Contractor) believes the Department is liable. By: ____________________ (The Contractor, Name and Title) Date of Execution: ________

105.18 CONTROL OF WORK

5. The name, title, and activity of each Contractor employee knowledgeable about facts that gaverise to such claim.

6. The specific provisions of the Contract that support the claim, and a statement why theprovisions support the claim.

7. A weekly listing of all construction equipment in use Or approved by the Resident Engineertobe held in standby condition due to the work whicb is the subject ofthe Claim to include thetype, make, model and year of manufacture. The listing will reflect hours that equipment wasin use or standby condition due to the work which is the subject of the claim. No equipmentclaim costs may be allowed for those periods of time for which the Contractor failed to file .the equipment listing.

8. The identification of any pertinent documents relating to the claim.

9. A statement whether the additional compensation or extension oftime is based on the provisionsof the Contract or an alleged breach of Contraet.

10. Ifan extension of time is also sought, the speeific days for which it is sought and the basis forsuch claim as detennined by an analysis of the Contractor's Progress Schedule as provided tothe Department pursuant to Subsection 108.03.a. or 108.03.b. prior to commencement ofProject work.

11. The amount of additional eompensation sought and a breakdown of that amount as providedin Section 109.04.

Failure to submit a claim prior to final payment on the Contract shall constitute a waiver of allclaims.

(b) Required Certification of Claims. The claim submittal shall include the Contractor's writtencertification, under oath, attesting to the following:

1. The claim is made in good faith.

2. Supportive data is accurate and complete to tbe Contractor's best knowledge and belief.

3. The amount of the claim accurately reflects the Contractor's true cost incurred.

4. The amount of the claim has been adjusted and reduced to reflect change orders related to theclaim for which the Contractor has previously been compensated.

In complying with this requirement, the Contractor shall use the Department's Certificate of Claimfonn as shown as follows:

SECTION 100 - PAGE 52 08/12/99

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00199.30(d)

123

(Part 7) Supporting documents (label page 7.1 through page 7.?) - Include copies of, or excerpts from the following:

• Any documents that support the claim, such as manuals standard to the industry and used by the Contractor; and

• Any daily reports or diaries related to the event, photographs or media that help explain the issue or event (optional), or all other information the Contractor chooses to provide (optional);

(Part 8) Contractor evaluation of a lower tier claim (label page 8.1 through 8.?) - If the claim includes Work done or costs incurred by a Subcontractor, Materials supplier, or any Entity other than the Contractor, the following are required:

• Data required by the other Subsections of 00199.30(b); • Copy of the Contractor's separate analysis and evaluation; • Copy of the Contractor's independent review and analysis of the amount of damages sought;

and (Part 9) Certification (label page 9.1 through 9.?) - A certified statement by the Contractor, Subcontractor or Materials supplier, as appropriate, as to the validity of facts and costs containing the following language:

Under penalty of law for perjury or falsification, the undersigned, (Name), (Title), (Company) certifies that this claim for additional compensation for Work on the Contract is a true statement of the actual costs incurred (in the amount of $________, exclusive of interest) and is fully documented and supported under the Contract between the parties.

Signature:

Date: ___________________, 20___

Subscribed and sworn before me this ____ day of , 20___

Notary Public My commission expires .

A person authorized to execute Change Orders on behalf of the Contractor must countersign this statement.

Claims shall be made in writing, and shall include all information necessary for the Agency to properly and completely analyze the claim. All pages shall have page numbers and be marked with the numbering system shown above. The Agency reserves the right at any time to request additional information related to the claim or the Contract either directly or through Agents working toward resolution of the disputed or claimed events and issues. (c) Records Required - The Contractor shall keep full and complete records of the actual costs incurred for the submitted claim. These records shall include all worksheets used to prepare the claim establishing the cost components for items of the claim. (d) Access to Records - The Contractor shall provide the Engineer access to all Contractor records required to determine the facts, contentions, and costs involved in the claim. The Engineer may perform an audit of these records. The Contractor shall retain all Contract records for a period of at least three years after Final Acceptance of the Project by the Agency, or until all disputes, including litigation, if any, are resolved (the "record retention period"). The Agency and/or its agents shall be provided full access to all Contract records during the record retention period.

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b. Submission. Claims must be submitted within 120 days of substantial completion of

the project. Claims submitted after 120 days will not be accepted. An equitable adjustment will

be made to the Contract if the claim is found to be just.

Nothing in this Subsection shall be construed as establishing any claim contrary to the

terms of Subsections 104.02; 104.03; 104.04; 104.05; 104.06 and 104.07 of these Standard

Specifications.

c. Documentation of Claims. Any claim shall be in sufficient detail to enable the

Engineer to determine the basis for entitlement and the resulting costs. The following minimum

information must accompany each claim submitted:

1. A detailed factual statement of the claim providing all necessary dates, locations and

items of work affected by the claim.

2. The date actions resulting in the claim occurred or conditions resulting in the claim

became evident.

3. A copy of the "Notice of Potential Claim" must be filed for the specific claim.

4. The name and title of each Department employee knowledgeable about facts that

gave rise to such claim.

5. The name and title of each Contractor or employee knowledgeable about facts that

gave rise to such claim.

6. The specific provisions of the Contract which support the claim, and a statement why

such provisions support the claim.

7. The identification of any pertinent documents, and the substance of any material or

communications relating to the claim.

8. A statement whether the additional compensation or extension of time is based on the

provisions of the Contract or an alleged breach of Contract.

9. If an extension of time is also sought, the specific days for which it is sought and the

basis for such claim as determined by an analysis of the construction schedule.

10. The amount of additional compensation sought and a breakdown of that amount.

d. Certification of Claims. When submitting a claim, the Contractor must certify in

writing, under oath in accordance with the formalities required as to the following:

1. The claim is made in good faith.

2. Supportive data is accurate and complete to the Contractor's best knowledge and

belief.

3. The amount of the claim accurately reflects the actual cost incurred by the Contractor.

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DOT 248A (12/06)

SOUTH DAKOTA DEPARTMENT OF TRANSPORTATION CONSTRUCTION CLAIM DOCUMENTATION

Please supply all of the following information for each claim within 30 days of receipt of this form. Attach additional sheets as necessary. Contractor Name & Address:______________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Business Phone:______________________________Alternate Phone:_____________________ Date Start of Project:__________________________Date End Project:____________________ Project Number:_________________________________PCN___________________________ Description of Project:___________________________________________________________ Summary of Claim:______________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Complete the following statement: Under the penalty of law for perjury or falsification, the undersigned, ____________________________________________,_______________________ (Printed Name) (Title) of ___________________________________, hereby certifies that the Claim for extra

(Company) compensation made herein for work on this project is a true statement of the actual costs incurred, and is fully documented and supported under the contract between the parties. I hereby agree that the Department or its authorized representative shall have the right to examine and copy all Contractor records, documents, work sheets, bid sheets, and other data which are pertinent to the justification of the claim and to the substantiation of all related cost data. ___________________________ _____________________________ (Signature) (Date) Subscribed and sworn before me this _________day of ______________20____. _________________________________ My Commission Expires ____ (Notary Public)

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Control of Work 00727 – Page 1 of 13

January 1, 2008

Utah Claims Specifications 1.23 ADDITIONAL COMPENSATION OR CONTRACT ADJUSTMENT CLAIMS

A. Notify the Engineer in writing of any intent to file a claim for additional compensation for work or material before beginning or continuing the affected work. 1. Follow the notification requirements for differing site conditions,

changes, and requests or claims for additional compensation under Section 00725.

2. The Engineer responds as described for differing site conditions changes, and requests or claims for additional compensation under Section 00725.

B. Work closely with the Engineer during notification, review, and evaluation

to resolve the contract question and avoid further claims. C. The Contractor waives any claim for additional compensation if the

Engineer is not notified or is not afforded proper facilities for strict accounting of actual costs. 1. Notifying the Engineer and accounting of costs does not

substantiate the claim’s validity 2. The contract will be adjusted only if the claim is found to have merit.

D. Submit claim with enough detail to enable the Engineer to understand the

basis for entitlement and the resulting costs. Include the following information with each claim submitted: 1. A detailed statement providing all necessary dates, locations, and

items of work affected by the claim. 2. The date on which actions or conditions resulting in the claim

occurred or became evident. 3. Name, title, and activity of each Department employee

knowledgeable about facts that are the basis of the claim. 4. Name, title, and activity of each Contractor employee

knowledgeable about facts that are the basis of the claim. 5. The specific contract provisions that support the claim and a

statement of why they support it. 6. Identification of pertinent documents and the substance of any

relevant verbal communications relating to the claim. 7. A statement whether the additional compensation or extension of

time is based on contract provisions or an asserted breach of contract.

8. For time extension or compensation for delay requests, include: a. The specific days for which a time extension is requested. b. The specific reasons a time extension should be granted.


January 1, 2008

c. Documents and reports specified for determining compensation and contract time extension for excusable delays under Section 00555.

9. Exact amount and specifics of additional compensation sought and a breakdown of the cost into the following categories: a. Direct labor b. Direct materials c. Direct equipment

1) Do not exceed actual cost on rates claimed for each piece of equipment.

2) The rates for the equipment in use cannot exceed the force account rates in the absence of actual equipment cost. Refer to Section 01282.

d. Field indirect costs e. Home office overhead f. Subcontractor's claims

1) Provide the same level of detail as specified in contract documents for any subcontractor’s claims.

10. Certification: Submit a statement to the Engineer containing the following language:

Under the penalty of law for perjury or falsification, the undersigned,

_____________________ __________________________________ Name Title Company

hereby certifies that the claim for extra compensation and time, if any, made herein for work on this contract is a true statement of the actual costs incurred and time sought, and is fully documented and supported under the contract between the parties.

Dated /s/ Subscribed and sworn before me this day of Notary Public My Commission Expires

E. Failure to either submit information and details as described in this section

for any claim or failure to submit any claim before the date of final acceptance constitutes a waiver of the claim.

1.24 CLAIMS RECORD KEEPING

A. Maintain complete records of all costs and additional time incurred for any alleged claim.

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January 1, 2008

B. Permit the Engineer access to those records and any other records as required to determine the facts or contentions involved in the claim.

C. Retain all records for a period of not less than three years after final

acceptance. 1.25 CLAIMS AUDITING

A. All claims filed against the Department are subject to audit at any time following filing the claim.

B. The Department or an auditor under contract with the Department may

conduct the audit. The audit may begin at any time during the life of the contract, or 20 calendar days after notice is provided to the Contractor, the subcontractors, or the Contractor’s agents if more than 60 calendar days after the final acceptance date of the contract have elapsed.

C. Provide adequate facilities acceptable to the Engineer for the audit during

normal business hours. Cooperate with the auditors. D. Failure of the Contractor, subcontractors, or agents to maintain and retain

sufficient records to allow the auditors to verify all or a portion of the claim or to permit the auditor access to the books and records of the Contractor, subcontractors, or agents constitutes a waiver of the claim and bars any recovery.

E. As a minimum, make the following documents available to auditors:

1. Daily time sheets and supervisor's daily reports 2. Union agreements, if any 3. Insurance, welfare, and benefits records 4. Payroll registers 5. Earnings records 6. Payroll tax forms 7. Material invoices, purchase orders, requisitions, and all material

and supply acquisition contracts 8. Material cost distribution work sheet 9. Equipment records including list of company equipment, rates, etc. 10. Vendor rental agreements and subcontractor invoices 11. Subcontractor payment certificates 12. Canceled checks (payroll and vendors) 13. Job cost report 14. Job payroll ledger 15. General ledger, general journal if used, and all subsidiary ledgers

and journals together with all supporting documentation pertaining to entries made in these ledgers and journals

16. Cash disbursements journal


January 1, 2008

17. Depreciation records on all company equipment used in performance of the work

18. All other documents used to develop costs for the Contractor’s internal purposes to establish the actual cost of owning and operating equipment used in performance of the work

19. All documents related to preparing the Contractor’s bid, including final documents on which the bid was based - Exclude documents placed in escrow

20. All documents that relate to each and every claim together with all documents that support the amount of damages as to each claim

21. Worksheets used to prepare the claim establishing the cost components for items of the claim including, but not limited to, labor, benefits and insurance, materials, equipment, subcontractors, all documents that establish the time periods, individuals involved, and the hours and rates for the individuals

F. Full compliance with the provisions of this article is a contractual condition

precedent to the right to seek judicial relief.


January 1, 2008

1.26 CLAIMS HIGHER LEVEL REVIEW

A. Provide written notification to the Engineer within 10 calendar days of the Engineer's denial of a claim requesting a higher-level review, when not accepting the Engineer’s denial action.

B. Failure to submit a request within this 10-day time frame is considered

acceptance of the Engineer’s denial action. 1.27 CLAIMS REVIEW BOARD

A. Pursue administrative resolution of any claim with the Engineer or the designee of the Engineer.

B. The Director for Construction and Materials schedules a hearing before

the Department Claims Review Board when deemed to be in the best interest of both the Contractor and the Department if no agreement is reached and at the Contractor’s written request to the Engineer. 1. The claim may be presented informally with or without legal

counsel. a. Notify the Department at least 10 calendar days before the

hearing when using legal counsel.

C. The Board makes recommendations and outlines their reasoning to the UDOT Deputy Director within 30 calendar days after the claim hearing.

D. The UDOT Deputy Director makes an offer of settlement within 45

calendar days after the claim hearing.

E. The decision of the UDOT Deputy Director is administratively final.

F. The Contractor has the option of rejecting and appealing the Department’s decision to the State Procurement Appeals Board in accordance with Utah Code Title 63, Chapter 56 – Utah Procurement Code.

PART 2 PRODUCTS Not Used PART 3 EXECUTION Not Used

END OF SECTION

Below is the claim certification format used when a Contractor submits a construction claim to Virginia DOT. The Contractor shall submit a certification with any claim using the following format:

Pursuant to Code of Virginia, I hereby certify that this contract claim submission for Virginia Department of Transportation Project ____________ in ______ County, Virginia is a true and accurate representation of additional costs and/or delays incurred by (name of Contractor) in the performance of the required contract work. Any statements made, and known to be false, shall be considered a violation of the Virginia Governmental Frauds Act, punishable as allowed by the Virginia Code for a Class 6 Felony.

(Company) By: As officer or duly appointed agent of (Company) Title: Date: State Of: City/County of _______________, To-Wit: I, the undersigned, a Notary Public in and for the City/ County and State aforesaid, do hereby certify that , whose name is signed to the foregoing instrument, bearing date of the______ day of , 20_, has this day acknowledged the same before me in my City/ County and State aforesaid.

Given under my hand this day of , 20_. Notary Public: My commission expires: Claims submitted during the statutory period for submitting contract claims and submitted without the certification described above shall not have standing as a claim and shall not be considered by the Department.

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Wisconsin Claim Certification Language 105.13.3 Content of Claim (1) Include the following 5 items in the claim.

1. A concise description of the claim. 2. A clear contractual basis for the claim. This should include reference to 104.2 on revisions to the contract and as appropriate, specific reference to contract language regarding the bid items in question. 3. Other facts the contractor relies on to support the claim. 4. A concise statement of the circumstances surrounding the claim and reasons why the department should pay the claim. Explain how the claimed work is a change to the contract work. 5. A complete breakdown of the costs used to compile the claim. Include copies of all blue book equipment rental rate sheets used, with the applicable number highlighted.

(2) The department may refer the claimant of a false claim to the appropriate authority for criminal prosecution. Certify the claim using the following form:

The undersigned is duly authorized to certify this claim on behalf of (the contractor). (The contractor) certifies that this claim is made in good faith, that the supporting data are accurate and complete to the best of (the contractor's) knowledge and belief, and that the amount requested accurately reflects the contract adjustment for which (the contractor) believes that the department is liable.

(THE CONTRACTOR) By:_____________________________________ (Name and Title) Date of Execution:_________________________

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Yes we do require the contractor to certify. I am enclosing the language we use. We do not require a separate form as such. Within 30 calendar days of notifying the engineer, send to the engineer for review and audit, accurate and complete documentation supporting the requested contract amendment; send by USPS certified mail, "Return Receipt Requested." Provide copies of pertinent data arranged in a logical sequence; include at least the following: 1. copies of all previous correspondence related to the activity or item of work disputed; 2. data and information used to assemble the bid, if bid preparation is relevant to the disputed issue; 3. schedules and updates prepared in accordance with subsection 108.3.2, "Schedule," if time or delays are relevant to the disputed issue; 4. documents similar in nature to those used to substantiate payments for extra or force account work, as specified in subsection 109.4.4(5), "Force Account, Documentation"; 5. supporting actual cost records; 6. accounting records and statements, if overhead is relevant to the disputed issue. Accompany the submission with the following signed statement: The undersigned is duly authorized to certify the enclosed documentation on behalf of (the contractor). (The contractor) certifies that the documentation is submitted in good faith, that the information provided is accurate and complete to the best of (the contractor's) knowledge and belief, and that the monetary amount requested accurately reflects the contract amendment for which (the contractor) believes the department is responsible. (THE CONTRACTOR) By: (Name and title) Date:

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