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 Contractor’s Project Claim #       or 
  
          (   ) No; this notice is to supplement the attached previous notice, referenced as Contractor’s Project Claim #      

3.	State (in a narrative) the nature of and circumstances/reasons of the act, failure to act, event, thing, occurrence, condition, cause of delay, or alleged suspension, which gives rise to this claim or protest (include the name, function, and activity of each individual involved in or  knowledgeable about the claim or protest and the identification of documents and the substance of communications relating to the claim or protest):
                

4.	State  the specific beginning date of such act, failure to act, event, thing, occurrence, condition, cause of delay, or alleged suspension which gives rise to this claim or protest:       (date)

5.	Will the change affect or could the change affect Contract Time? 

(   ) No; or

(   ) Yes, the time impact is:      days (Provide the basis as per Subsection 108.04 of the 2001 Specifications); or
(   ) Yes, but the time impact will not be known until (list date)       or completion of activities described:       
6.	Is the dollar amount of this claim known? 

           (   ) Yes; the amount of this claim is $        or
                    (Provide the basis for the calculation, including all types of all costs incurred, using additional pages as necessary)

           (   ) No; the amount of this claim is unknown at this time but a non-binding estimate is (check applicable box):

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

7.	State the Pay Item(s) that have been or will be affected by this claim or protest:
                

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

        (   ) 104.04- Protest 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)           

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

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

(   ) No; this Form is incomplete; it is submitted to provide notice under N.J.S.A. 59:13-1, et seq. and specification 104.09, 
                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 knowingly or willfully false, I am subject to such punishment as may be provided by all applicable laws, including but not limited to the New Jersey False Claims Act, N.J.S.A. 2A:32C-1, et seq.

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.

COPIES OF THIS NOTICE SHOULD ALSO BE MAILED TO THOSE AS DIRECTED BY THE RESIDENT ENGINEER.