Form CEM-6201C "Full and Final Documentation of Potential Claim" - California

What Is Form CEM-6201C?

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-6201C 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-6201C "Full and Final Documentation of Potential Claim" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
FOR STATE USE ONLY
FULL AND FINAL DOCUMENTATION OF
Received By
(For resident engineer)
Date
POTENTIAL CLAIM
CEM-6201C (NEW 9/2002)
TO
CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
(resident engineer)
This is the Full and Final Documentation 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:
DATE:
The complete and factual narration of events which fully describe the nature and circumstances that caused the dispute or disagreement and potential
claim are attached hereto.
(attach sheets as required for full and final documentation)
The basis of this claim including all relevant contract provisions and a statement of the reasons these provisions support and provide basis for
entitlement of the potential claim are attached hereto.
(attach sheets as required for full and final documentation)
The identification and copies of any documents and substance of any oral communication that support the potential claim are attached hereto.
(attach sheets as required for full and final documentation)
The exact dollar amount requested and an itemized breakdown of individual costs segregated by labor, materials, equipment and other are attached
hereto.
(attach sheets as required for full and final documentation)
The exact amount of any time adjustment requested including justification thereof and time impact analysis are attached hereto.
(attach sheets as required for full and final documentation)
The undersigned originator (Contractor or Subcontractor as appropriate) certifies that the above statements and attached documentation
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 information, call (916) 445-1233,
ADA Notice
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
FULL AND FINAL DOCUMENTATION OF
Received By
(For resident engineer)
Date
POTENTIAL CLAIM
CEM-6201C (NEW 9/2002)
TO
CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
(resident engineer)
This is the Full and Final Documentation 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:
DATE:
The complete and factual narration of events which fully describe the nature and circumstances that caused the dispute or disagreement and potential
claim are attached hereto.
(attach sheets as required for full and final documentation)
The basis of this claim including all relevant contract provisions and a statement of the reasons these provisions support and provide basis for
entitlement of the potential claim are attached hereto.
(attach sheets as required for full and final documentation)
The identification and copies of any documents and substance of any oral communication that support the potential claim are attached hereto.
(attach sheets as required for full and final documentation)
The exact dollar amount requested and an itemized breakdown of individual costs segregated by labor, materials, equipment and other are attached
hereto.
(attach sheets as required for full and final documentation)
The exact amount of any time adjustment requested including justification thereof and time impact analysis are attached hereto.
(attach sheets as required for full and final documentation)
The undersigned originator (Contractor or Subcontractor as appropriate) certifies that the above statements and attached documentation
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 information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.