Form CEM-6201B "Supplemental Notice of Potential Claim" - California

What Is Form CEM-6201B?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2002;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-6201B by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-6201B "Supplemental Notice of Potential Claim" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
FOR STATE USE ONLY
SUPPLEMENTAL NOTICE OF POTENTIAL CLAIM
Received By
Date
CEM-6201B (NEW 09/2002)
(For resident engineer)
TO
CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
(resident engineer)
This is a Supplemental Notice of Potential Claim for additional compensation submitted as required under the provisions of Section 9-1.04,
"Notice of Potential Claim," of the Standard Specifications. The act of the engineer, or his/her failure to act, or the event, thing, occurrence,
or other cause giving rise to the potential claim occurred on:
The particular nature and circumstances of this potential claim are described in detail as follows:
(attach additional sheets as needed)
The basis of this potential claim including all relevant contract provisions are listed as follows:
(attach additional sheets as needed)
The estimated dollar cost of the potential claim including a description of how the estimate was derived and an itemized breakdown of individual costs
are attached hereto.
(attach sheets as required)
A time impact analysis of the disputed disruption has been performed and is attached hereto. The affect on the scheduled project completion date is as
follows:
The undersigned originator (Contractor or Subcontractor as appropriate) certifies that the above statements and attached documents are
made in full cognizance of the California False Claims Act, Government Code sections 12650-12655. The undersigned further understands
and agrees that this potential claim to be further considered, unless resolved, must fully conform to the requirements in Section 9-1.04 of
the Standard Specifications and must be restated as a claim in the Contractors written statement of claims in conformance with Section
9-1.07B of the Standard Specifications.
SUBCONTRACTOR or CONTRACTOR
(Circle One)
(Authorized Representative)
For a subcontractor potential claim
This notice of potential claim is acknowledged, certified and forwarded by
PRIME CONTRACTOR
(Authorized Representative)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
FOR STATE USE ONLY
SUPPLEMENTAL NOTICE OF POTENTIAL CLAIM
Received By
Date
CEM-6201B (NEW 09/2002)
(For resident engineer)
TO
CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
(resident engineer)
This is a Supplemental Notice of Potential Claim for additional compensation submitted as required under the provisions of Section 9-1.04,
"Notice of Potential Claim," of the Standard Specifications. The act of the engineer, or his/her failure to act, or the event, thing, occurrence,
or other cause giving rise to the potential claim occurred on:
The particular nature and circumstances of this potential claim are described in detail as follows:
(attach additional sheets as needed)
The basis of this potential claim including all relevant contract provisions are listed as follows:
(attach additional sheets as needed)
The estimated dollar cost of the potential claim including a description of how the estimate was derived and an itemized breakdown of individual costs
are attached hereto.
(attach sheets as required)
A time impact analysis of the disputed disruption has been performed and is attached hereto. The affect on the scheduled project completion date is as
follows:
The undersigned originator (Contractor or Subcontractor as appropriate) certifies that the above statements and attached documents are
made in full cognizance of the California False Claims Act, Government Code sections 12650-12655. The undersigned further understands
and agrees that this potential claim to be further considered, unless resolved, must fully conform to the requirements in Section 9-1.04 of
the Standard Specifications and must be restated as a claim in the Contractors written statement of claims in conformance with Section
9-1.07B of the Standard Specifications.
SUBCONTRACTOR or CONTRACTOR
(Circle One)
(Authorized Representative)
For a subcontractor potential claim
This notice of potential claim is acknowledged, certified and forwarded by
PRIME CONTRACTOR
(Authorized Representative)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.