NEW JERSEY DEPARTMENT OF TRANSPORTATION
CONTRACTUAL NOTICE FORM 

THE CONTRACTOR IS ADVISED THAT THERE ARE SPECIFIC TIME LIMITS FOR FILING NOTICES UNDER BOTH THE CONTRACT SPECIFICATIONS AND THE NEW JERSEY CONTRACTUAL LIABILITY ACT, N.J.S.A. 59:13-1, ET SEQ. (THE CONTRACTUAL LIABILITY ACT.).  THE CONTRACTOR MUST COMPLY WITH THE TIME REQUIREMENTS OF BOTH THE SPECIFICATIONS AND THE CONTRACTUAL LIABILITY ACT IN ORDER TO FULLY RESERVE THIS CLAIM.  THE CONTRACTOR UNDERSTANDS THAT IF IT FAILS TO GIVE NOTICE AS REQUIRED BY THE SPECIFICATIONS WITHIN THE TIME PROVIDED, ANY CLAIM MAY BE FOREVER BARRED OR LIMITED AS PROVIDED BY THE SPECIFICATIONS.  THE CONTRACTOR ALSO UNDERSTANDS THAT IT MAY BE BARRED FROM RECOVERING AGAINST THE STATE IF IT FAILS TO GIVE NOTICE OF ANY ACT OR FAILURE TO ACT BY THE NEW JERSEY DEPARTMENT OF TRANSPORTATION, OR THE HAPPENING OF ANY EVENT, THING OR OCCURRENCE WITHIN 90 DAYS OF SUCH ACT, FAILURE TO ACT, OR HAPPENING OF SUCH EVENT, THING OR OCCURRENCE IN ACCORDANCE WITH THE CONTRACTUAL LIABILITY ACT, EXCEPT IF PERMISSION TO FILE A LATE NOTICE OF CLAIM IS OBTAINED FROM THE SUPERIOR COURT WITHIN ONE YEAR OF THE ACCRUAL OF THE CLAIM.

THIS FORM MUST BE USED TO FILE ANY NOTICE OR PROTEST REQUIRED BY THE CONTRACT SPECIFICATIONS.  THE TIMELY FILING OF THIS FORM, COMPLETED IN ITS ENTIRETY, ALSO SATISFIES THE NOTICE REQUIREMENT OF THE CONTRACTUAL LIABILITY ACT.  IF THE CONTRACTOR FILES THIS FORM WITHIN THE TIME LIMITS REQUIRED FOR A NOTICE PURSUANT TO THE SPECIFICATIONS, THE NOTICE REQUIREMENT OF THE CONTRACTUAL LIABILITY ACT WILL ALSO BE DEEMED TO HAVE BEEN SATISFIED.

	     	 	     	
	Name of Contractor		Street Address	
	                                                  		     	     	     	
	Business Phone Number                      Fax Number		  City   	     State	   Zip Code	
	     	
	                          Project Name, Section, Location and Description
			
1.	State whether this is a claim or a protest:
                ;

2.	Is this the first written notice made to the Department regarding this claim or protest? 

          (   ) Yes, please reference as Project Claim #      ; or 
  
          (   ) No, attached is a copy of the first notice. This notice is to supplement a previous notice, referenced as Project Claim #      

3.	State the nature of the act, failure to act, event, thing, occurrence, condition, cause of delay, or alleged suspension which gives rise to this claim or protest:
                ;

4.	State the reason(s), specifically the act, failure to act, event, thing, occurrence, condition, cause of delay, or alleged suspension which gives rise to this claim or protest:
                  ;     

5.	State specifically the beginning date of such act, failure to act, event, thing, occurrence, cause of delay, or alleged suspension which gives rise to this claim or protest: 
                ;

6.	State the Pay Items affected by this claim or protest:
                ;

7.	State the dollar amount of this claim or protest: $      ; 

8.	State the basis for the calculation of the dollar amount of this claim or protest.  Include a listing of all types of costs, which have been incurred or which are being incurred (use additional pages as necessary):  
                ;

9.	If the dollar amount of this claim or protest is unknown at this time, provide a non-binding estimate within the following ranges (check applicable box):

           (   ) less than $20,000; (   ) between $20,000 - $250,000; (   ) between $250,000 - $1,000,000; or (   ) more than $1,000,000

10.	State the impact to Contract Time:
                days;

(If an extension of contract time is sought, provide the specific days sought and the basis for such claim, supported by the Contractor’s approved baseline progress schedule and updates, as well as a fragnet, which will include a time impact evaluation, depicting the delay according to Subsection 108.04 of the 2001 Specifications)

11.	If the impact to Contract Time of this claim or protest is unknown at this time, state when all of the impacts to Contract Time will be known (state the date or completion of the specific activities or the event): 
                ;

12.	Identify the section(s) of the specifications on which the Contractor is basing this claim or protest (check the applicable boxes):

        (   ) 104.04- Protest change order no.       ;         (   ) 104.08- Extra Work;                            (   ) 109.03- Force Account Payment;                       

        (   ) 104.05- Increase/Decreased Quantities;            (   ) 108.09- Unusual Site Condition;         (   ) 109.04- Delays (Force Account);                       

        (   ) 104.06- Eliminated Items;                                 (   ) 108.11- Contract Time;                       (   ) 109.10- As-Built Quantities; 

        (   ) 104.07- Character of Work;                               (   ) 108.14-Work Suspension;                   (   ) Other (Specify)           

	
13.	Is the Contractor notifying the Department to begin the Contractual Claims Resolution Process? 

           (   ) Yes, this Form is complete in its entirety, including all costs and all proof(s) thereof submitted.

(   ) No, this Form is incomplete, with the costs of the claim unknown or partially unknown at this time.  

	   I certify that the foregoing statements made by me are true.  I am aware that if any of the foregoing 
          statements made by me are willfully false, I am subject to such punishment as may be provided by law.

DATED:	     			
		Signature-Prime Contractor’s Authorized Representative	
		     	
		(Type - Name and Title)	

           If correspondence relative to this form should be sent to someone other than the Contractor, please state Name and Address:

                

THE ORIGINAL OF THIS NOTICE MUST BE MAILED TO THE RESIDENT ENGINEER AT THE PROJECT’S FIELD OFFICE

AND COPIES OF THIS NOTICE MUST ALSO BE MAILED TO THOSE LISTED AS PER 107.02 OF THE SPECIAL PROVISIONS.