Form CEM-6201E "Supplemental Potential Claim Record" - California

What Is Form CEM-6201E?

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, 2014;
  • 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-6201E 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-6201E "Supplemental Potential Claim Record" - California

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FOR STATE USE ONLY
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SUPPLEMENTAL POTENTIAL CLAIM RECORD
Received By
Date
CEM-6201E (REV 9/2014)
(For resident engineer)
TO
(RESIDENT ENGINEER) CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
This is a Supplemental Potential Claim Record for additional compensation and/or days submitted as required under the provisions of
Section 5-1.43, "Potential Claims and Dispute Resolution," of the Standard Specifications. The initial potential claim record was submitted
on:
DATE
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 and a statement of the reasons these provisions support and provide basis for
entitlement of the potential claim is 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.
(attach additional sheets as needed)
A time impact analysis of the disputed disruption has been performed and is attached. 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 also understands and
agrees that this potential claim to be further considered, unless resolved, must fully conform to the requirements in Section 5-1.43,
"Potential Claims and Dispute Resolution," of the Standard Specifications and must be restated as a claim in the contractor's written claim
statement in conformance with Section 9-1.17D, "Final Payment and Claims" of the Standard Specifications.
SUBCONTRACTOR
CONTRACTOR
(Authorized Representative)
For a subcontractor potential claim
This potential claim record 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.
FOR STATE USE ONLY
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SUPPLEMENTAL POTENTIAL CLAIM RECORD
Received By
Date
CEM-6201E (REV 9/2014)
(For resident engineer)
TO
(RESIDENT ENGINEER) CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
This is a Supplemental Potential Claim Record for additional compensation and/or days submitted as required under the provisions of
Section 5-1.43, "Potential Claims and Dispute Resolution," of the Standard Specifications. The initial potential claim record was submitted
on:
DATE
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 and a statement of the reasons these provisions support and provide basis for
entitlement of the potential claim is 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.
(attach additional sheets as needed)
A time impact analysis of the disputed disruption has been performed and is attached. 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 also understands and
agrees that this potential claim to be further considered, unless resolved, must fully conform to the requirements in Section 5-1.43,
"Potential Claims and Dispute Resolution," of the Standard Specifications and must be restated as a claim in the contractor's written claim
statement in conformance with Section 9-1.17D, "Final Payment and Claims" of the Standard Specifications.
SUBCONTRACTOR
CONTRACTOR
(Authorized Representative)
For a subcontractor potential claim
This potential claim record 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.