Form CEM-6201F "Full and Final Potential Claim Record" - California

What Is Form CEM-6201F?

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 October 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-6201F 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-6201F "Full and Final Potential Claim Record" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
FOR STATE USE ONLY
FULL AND FINAL POTENTIAL CLAIM RECORD
CEM-6201F (REV 10/2014)
Received By
Date
(For resident engineer)
TO
(
) CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
RESIDENT ENGINEER
This is the Full and Final 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 completion date of the potentially claimed
work was:
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.
(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.
(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.
(attach sheets as required for full and final documentation)
The exact amount of any time adjustment requested including time impact analysis is attached.
(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.
(attach sheets as required for full and final documentation)
Relevant information, references, and arguments that support the potential claim.
(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 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 contractors written claim statement in
conformance with Section 9-1.17D(2), "Claim Statement," of the Standard Specifications.
SUBCONTRACTOR
CONTRACTOR
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
FOR STATE USE ONLY
FULL AND FINAL POTENTIAL CLAIM RECORD
CEM-6201F (REV 10/2014)
Received By
Date
(For resident engineer)
TO
(
) CONTRACT NUMBER
DATE
IDENTIFICATION NUMBER
RESIDENT ENGINEER
This is the Full and Final 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 completion date of the potentially claimed
work was:
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.
(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.
(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.
(attach sheets as required for full and final documentation)
The exact amount of any time adjustment requested including time impact analysis is attached.
(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.
(attach sheets as required for full and final documentation)
Relevant information, references, and arguments that support the potential claim.
(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 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 contractors written claim statement in
conformance with Section 9-1.17D(2), "Claim Statement," of the Standard Specifications.
SUBCONTRACTOR
CONTRACTOR
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.