NJSDA Form 505
Page 1 of 2
NJSDA Form 505
Revised: September 2016
District Name:
School Name:
Project Manager:
Contract No.:
Submit original claim and all related documentation to:
Division of Chief Counsel
32 E. Front Street
P.O. Box 991
Trenton, NJ 08625
Send a complete copy of the 505 and all related attachment(s) to the PMF/CM and the NJSDA Project Manager.
Claimant Name:
State: Zip:
Contact Name:
Contact Phone No.:
Description of Claim:
Total Dollar Amount of the Claim:
NJSDA Use Only
Date Received:
Received By:
Print Name of Claimant Representative:
Signature of Claimant Representative:
NJSDA Form 505
Page 2 of 2
NJSDA Form 505
Revised: September 2016
1. Entitlement
Claimant has described the factual, technical, contractual and legal bases supporting the claim. If the claim
includes a "pass-through" claim on behalf of a subcontractor or supplier, this should also be described and
2. Damages
Claimant has summarized the calculations and support for the compensation claimed. Claimant has
also summarized the methodology utilized to calculate these costs.
3. Documentation
Claimant has provided all documentation in support of its claim, including, but not limited to, change order
requests, requests for amendment, and all other supporting documents and correspondence relating thereto.
Claimant is required to submit a complete package and cannot include any documentation by reference.
Electronic copies may be submitted in lieu of hard copies.
4. Schedule Data and Updates
Claimant has submitted all schedule updates together with related dates including fragnets and/or networks
with supporting documentation in both scheduled and hard copy and in electronic format. Documentation
should also include any Time Impact Analysis or similar time analysis or reports.
5. Job Cost Reports
Claimant has submitted all job cost report data relevant to its claim in electronic format and hard copy.
6. Employee Pay Records
Claimant has provided all relevant employee pay and time records of its company and its subcontractor,
if the subcontractor is part of the claim.
7. Photos / Videos
Claimant has provided existing photographic or video representations of the nature of the work under
8. Requested Additional Supporting Documentation
Claimant may be required to submit additional documentation upon request by the NJSDA. Failure to
provide the requested applicable, relevent documentation may result in rejection of the claim.
Print Form