Form CEM-5101 "Request for Payment for Materials on Hand" - California

What Is Form CEM-5101?

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 April 1, 2018;
  • 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-5101 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-5101 "Request for Payment for Materials on Hand" - California

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REQUEST FOR PAYMENT FOR MATERIALS ON HAND
CEM-5101 (REV 04/2018)
PROJECT INFORMATION/NAME
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
CONTRACTOR NAME
TO: RESIDENT ENGINEER (Name)
FROM: CONTRACTOR'S REPRESENTATIVE (Name) DATE:
In accordance with the provisions of Section 9-1.16C of the Standard Specifications, request is made for payment as "Materials on Hand" for the
following materials:
TYPE OF
CONTRACTOR OR
DVBE, DBE,
SUBSTANTIATING
MATERIAL
WHERE STORED
SUBCONTRACTOR
SB, OR NA
ITEM NO QUANTITY
VALUE
EVIDENCE OF
DESCRIPTION
(see Note 2)
(Name of Requestor)
(see Note 1)
PURCHASE
ATTACHED
Material cost invoice
Example:
Fenced McGregor
and trucking cost
I.M. Subcontractor,
DVBE
48
1,500 CY
Class 2 AB
$27,500
Property adjacent to A-
invoice with load
Inc.
line Sta. 244+50 LT
tickets
AFFIDAVIT:
The materials listed above have been purchased exclusively for use on the above-referenced project. The material is separated from other like
materials and is physically identified as our property for use on Contract
. California Department
of Transportation (Caltrans) may enter upon the premises for the purposes set forth in Section 6 of the Standard Specifications for inspection,
checking or auditing, or for any other purpose it considers necessary. It is expressly understood and agreed that this information and affidavit
are furnished to Caltrans for the purpose of obtaining payment for the above materials before they are delivered to, or incorporated into, the
project described above, and that the storage thereof at the location shown is subject to, and under the control of, Caltrans. A revised form
showing the current status of the value of materials for which payment is being requested will be submitted each estimate period.
SIGNATURE OF CONTRACTOR:
DATE:
Notes:
1) Disabled Veteran Business Enterprise, Disadvantaged Business Enterprise, Small Business, or Not Applicable.
2) When stored at a location other than on the jobsite or at a fabricator's yard, a warehouse receipt for the materials issued in the name of the
state shall accompany the request for payment. In case the storage location (other than the jobsite or fabricator's yard) is the contractor's
property, the area containing the material to be paid for shall be fenced and posted to indicate that the material within the fenced area is
under the control of Caltrans.
INSTRUCTIONS TO CONTRACTOR:
Submit original and one copy to resident engineer not later than one week prior to the end of the estimate period. Attach evidence of purchase
(and warehouse receipt when required) to original.
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.
REQUEST FOR PAYMENT FOR MATERIALS ON HAND
CEM-5101 (REV 04/2018)
PROJECT INFORMATION/NAME
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
CONTRACTOR NAME
TO: RESIDENT ENGINEER (Name)
FROM: CONTRACTOR'S REPRESENTATIVE (Name) DATE:
In accordance with the provisions of Section 9-1.16C of the Standard Specifications, request is made for payment as "Materials on Hand" for the
following materials:
TYPE OF
CONTRACTOR OR
DVBE, DBE,
SUBSTANTIATING
MATERIAL
WHERE STORED
SUBCONTRACTOR
SB, OR NA
ITEM NO QUANTITY
VALUE
EVIDENCE OF
DESCRIPTION
(see Note 2)
(Name of Requestor)
(see Note 1)
PURCHASE
ATTACHED
Material cost invoice
Example:
Fenced McGregor
and trucking cost
I.M. Subcontractor,
DVBE
48
1,500 CY
Class 2 AB
$27,500
Property adjacent to A-
invoice with load
Inc.
line Sta. 244+50 LT
tickets
AFFIDAVIT:
The materials listed above have been purchased exclusively for use on the above-referenced project. The material is separated from other like
materials and is physically identified as our property for use on Contract
. California Department
of Transportation (Caltrans) may enter upon the premises for the purposes set forth in Section 6 of the Standard Specifications for inspection,
checking or auditing, or for any other purpose it considers necessary. It is expressly understood and agreed that this information and affidavit
are furnished to Caltrans for the purpose of obtaining payment for the above materials before they are delivered to, or incorporated into, the
project described above, and that the storage thereof at the location shown is subject to, and under the control of, Caltrans. A revised form
showing the current status of the value of materials for which payment is being requested will be submitted each estimate period.
SIGNATURE OF CONTRACTOR:
DATE:
Notes:
1) Disabled Veteran Business Enterprise, Disadvantaged Business Enterprise, Small Business, or Not Applicable.
2) When stored at a location other than on the jobsite or at a fabricator's yard, a warehouse receipt for the materials issued in the name of the
state shall accompany the request for payment. In case the storage location (other than the jobsite or fabricator's yard) is the contractor's
property, the area containing the material to be paid for shall be fenced and posted to indicate that the material within the fenced area is
under the control of Caltrans.
INSTRUCTIONS TO CONTRACTOR:
Submit original and one copy to resident engineer not later than one week prior to the end of the estimate period. Attach evidence of purchase
(and warehouse receipt when required) to original.
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.