Form MDT-CON-105-16-2 "Contractor Certified Claim" - Montana

What Is Form MDT-CON-105-16-2?

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

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Montana 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 MDT-CON-105-16-2 by clicking the link below or browse more documents and templates provided by the Montana Department of Transportation.

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Download Form MDT-CON-105-16-2 "Contractor Certified Claim" - Montana

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Submit to:
Montana Department of Transportation
MDT Project Manager
and in accordance with
Contractor Certified Claim
Subsection 106.16
MDT-CON-105-16-2 REV.02/2021
Page 1 of 5
This form is an interactive form, text boxes expand upon entry.
Project Manager:
Fed/State Project Number:
Prime Contractor:
Project Description:
Contract ID:
Control Number:
Date of Notice of Claim:
Claim #:
Date of Disagreement or Discovery:
Does Claim involve Lower Tier Subcontractor? Yes
No
Certification of each part of a claim is a prerequisite to a claim being considered by the Department.. Do not alter the language of
this form.
Anyone knowingly presenting a claim, any part of which is found to be false or fraudulent, is subject to the criminal penalties of
§45-7-210, MCA, and civil liabilities of §17-8-403, MCA, in addition to criminal and civil penalties applicable under Federal law.
The Contractor understands and agrees that, under its contract with the Department, it must certify any claim. Failure to fully
certify the claim as required herein is a failure to utilize the Department's procedure for dispute settlement, and bars further
administrative or judicial review of the claim.
Understanding the above, and with the intent to obtain the claimed amount from the State, the Contractor by the undersigned
certifies that:
a. this claim is made in good faith;
b. the Contractor has fully reviewed the claim and its supporting data, including its project records (and the project records
of any Subcontractor work associated with the Contractor's claim) to ensure that any personnel and equipment items
listed in the claim are properly included;
c. the supporting data are accurate and complete to the best of the Contractor's knowledge and belief, and support that all
personnel and equipment items listed in the claim are properly included; n
d. no part of the claim is false or fraudulent; and,
e. the amount requested, as shown on the attached pages, accurately reflects the contract adjustment for which the
Contractor believes the State is liable, and is a complete statement of the claim.
Only claims from the Contractor will be accepted. A claim may not be submitted by a Subcontractor. The Contractor cannot pass
a Subcontractor's claim through to the Department.
Do not change the basis of a claim after submitting the written notice of claim. A notice of claim is required for each separate
claim that may be filed. Attach additional pages if required.
In accordance with Subsection 105.16, the undersigned contractor makes a claim for additional compensation, additional time, or
other consideration for this Project:
Submit to:
Montana Department of Transportation
MDT Project Manager
and in accordance with
Contractor Certified Claim
Subsection 106.16
MDT-CON-105-16-2 REV.02/2021
Page 1 of 5
This form is an interactive form, text boxes expand upon entry.
Project Manager:
Fed/State Project Number:
Prime Contractor:
Project Description:
Contract ID:
Control Number:
Date of Notice of Claim:
Claim #:
Date of Disagreement or Discovery:
Does Claim involve Lower Tier Subcontractor? Yes
No
Certification of each part of a claim is a prerequisite to a claim being considered by the Department.. Do not alter the language of
this form.
Anyone knowingly presenting a claim, any part of which is found to be false or fraudulent, is subject to the criminal penalties of
§45-7-210, MCA, and civil liabilities of §17-8-403, MCA, in addition to criminal and civil penalties applicable under Federal law.
The Contractor understands and agrees that, under its contract with the Department, it must certify any claim. Failure to fully
certify the claim as required herein is a failure to utilize the Department's procedure for dispute settlement, and bars further
administrative or judicial review of the claim.
Understanding the above, and with the intent to obtain the claimed amount from the State, the Contractor by the undersigned
certifies that:
a. this claim is made in good faith;
b. the Contractor has fully reviewed the claim and its supporting data, including its project records (and the project records
of any Subcontractor work associated with the Contractor's claim) to ensure that any personnel and equipment items
listed in the claim are properly included;
c. the supporting data are accurate and complete to the best of the Contractor's knowledge and belief, and support that all
personnel and equipment items listed in the claim are properly included; n
d. no part of the claim is false or fraudulent; and,
e. the amount requested, as shown on the attached pages, accurately reflects the contract adjustment for which the
Contractor believes the State is liable, and is a complete statement of the claim.
Only claims from the Contractor will be accepted. A claim may not be submitted by a Subcontractor. The Contractor cannot pass
a Subcontractor's claim through to the Department.
Do not change the basis of a claim after submitting the written notice of claim. A notice of claim is required for each separate
claim that may be filed. Attach additional pages if required.
In accordance with Subsection 105.16, the undersigned contractor makes a claim for additional compensation, additional time, or
other consideration for this Project:
Submit to:
Montana Department of Transportation
MDT Project Manager
and in accordance with
Contractor Certified Claim
Subsection 106.16
MDT-CON-105-16-2 REV.02/2021
Page 2 of 5
This form is an interactive form, text boxes expand upon entry.
1. Summary. Include a detailed, factual statement of the claim for additional compensation and contract time, if any, with
necessary dates and locations of work involved in the claim. Also include detailed facts supporting the Contractor's position.
(Label any attachments for this item as page 1.1 through 1.X)
2. Proof of Notice. Submit notice of claim with all attachments that was furnished to the Department.
(Label any attachments for this item as page 2.1 through 2.X)
3. Supporting Documents. Furnish copies of the contract specifications that support the Contractor's claim.
(Label any attachments for this item as page 3.1 through 3.X)
4. Theory of Entitlement. Include a narrative of how or why the specific contract specifications support the claim.
(Label any attachments for this item as page 4.1 through 4.X)
5. Itemized Lists. Provide an itemized list of claimed damages that resulted from the event with a narrative of the theories
and records and documents used to arrive at the value of the damages.
(Label any attachments for this item as page 5.1 through 5.X)
6. Time Requests. Provide additional contract time requests if the claim is for a combination of additional compensation and
contract time. Submit a copy of the schedule that was in effect when the event occurred and a detailed narrative which
explains how the event impacted contract time. (Label any attachments for this item as page 6.1 through 6.X)
Submit to:
Montana Department of Transportation
MDT Project Manager
and in accordance with
Contractor Certified Claim
Subsection 106.16
MDT-CON-105-16-2 REV.02/2021
Page 3 of 5
This form is an interactive form, text boxes expand upon entry.
If the Department-caused delay is claimed, provide the following:
a. Include the specific days and dates under claim.
b. Provide detailed facts about the specific acts or omissions of the Department that allegedly caused the delay, and the
specific reasons why the resulting delay was unreasonable.
c. Provide a schedule evaluation that accurately describes the impacts of the claimed delay
7. Expense Records. Submit copies of actual expense records. Include documents that contain the detailed records which
support and total to the exact amount of additional compensation requested. Include the information and calculations
necessary to support that amount. At a minimum, provide the following:
1. Direct materials.
2. Direct equipment. The rate claimed for each piece of equipment not to exceed the actual cost. For each piece of
equipment, include a detailed description of the equipment and attachments, specific days and dates of use or
standby, and specific hours of use or standby.
3. Direct labor; and
4. Other categories as specified by the Contractor or the Agency.
(Label any attachments for this item as page 7.1 through 7.X)
8. Supporting Records. Provide additional supporting records and documents including copies of, or excerpts from the
following:
1. Any documents that support the claim, such as manuals standard to the industry and used by the Contractor; and
2. Any daily reports or diaries related to the event, photographs or media that help explain the issue or event.
(Label any attachments for this item as page 8.1 through 8.X)
9. Certification. Provide a certified statement, signed by a representative authorized to execute change orders, by the
Contractor, subcontractor, supplier, or entity originating the claim as to the validity of facts and costs
(Label any attachments for this item as page 9.1 through 9.X)
Submit to:
Montana Department of Transportation
MDT Project Manager
and in accordance with
Contractor Certified Claim
Subsection 106.16
MDT-CON-105-16-2 REV.02/2021
Page 4 of 5
This form is an interactive form, text boxes expand upon entry.
10. Lower Tier Claim. If the claim includes work done or costs incurred by any subcontractors, suppliers, or any entity other
than the Contractor, the following are required:
1. Copies of the Contractor's, subcontractor's, supplier's and entity's (at all tiers above the level of which the claim
originates) separate evaluation of entitlement.
2. Copies of the Contractor's, subcontractor's, supplier's and entity's (at all tiers above the level of which the claim
originates) independent verification and evaluation of the amount of damages sought; and
3. An authorized representative to execute change orders on behalf of the Contractor, Subcontractor, Supplier and
Entity (at all tiers above the level of which the claim originates).
(Label any attachments for this item as page 10.1 through 10.X)
11. Other Considerations:
Submit to:
Montana Department of Transportation
MDT Project Manager
and in accordance with
Contractor Certified Claim
Subsection 106.16
MDT-CON-105-16-2 REV.02/2021
Page 5 of 5
This form is an interactive form, text boxes expand upon entry.
Do not alter the verbiage in this form in any way. If a submitted form's verbiage is altered in any way, the form will be rejected
and the Contractor waives the claim and any compensation, time extension, or other consideration.
If the Project Manager determines that additional information, records, or documentation is needed to allow proper evaluation
of the claim submittal, the Project Manager will request the information, records, or documentation. Submit the requested
information to the Project Manager within14 calendar days.
If the claim includes requests for delay compensation, follow all procedures in Subsection 108.07.6.
ACKNOWLEDGEMENT
Prime Contractor's Representative
Representative's Title
Signature
Date
SUB-CONTRACTOR ACKNOWLEDGEMENT
Sub Contractor Name
Sub Contractor's Representative
Representative's Title
Signature
Date
Add Sub-Contractor
Remove Sub-Contractor
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