Office of the Administrative Law Judge
Ten Park Plaza, Suite 6620
Boston, MA 02116
(857) 368-9495
S T A T E M E N T O F C L A I M
1. Name of Contractor: _______________________________________________________________
2. Address of Contractor: _____________________________________________________________
3. Contract Number: ____________________________ Award Amount: ______________________
4. Date of Award: ___________________
5.
City or Town where project is located: ________________________________________________
6. Please state (a) the date you made your initial claim in writing to the Engineer, (b) the nature of
your claim, (c) attach a copy of the initial claim & claims committee determination, and (d) any
additional pending claims.
a. Date of Claim: _____________________
b. Nature of Claim: ____________________ (i.e., extra work, changed condition, delay, etc...)
c. Initial Notice of Claim attached as Exhibit: _____ Claims Committee Letter as Exhibit: _____
d. Do you have additional claims pending review by this office, the claims committee, or the
Superior Court of Massachusetts (yes/no): _____ If yes, please attach as Exhibit: _____
7. Please provide a detailed factual account of your claim (please use additional paper if necessary):
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8. Please state (a) the amount of your claim, (b) attach a detailed good faith breakdown to show how
the claim amount was derived, and (c) liquidated damages assessment where applicable.
a. Amount of Claim: _________________________
b. Detailed breakdown attached hereto as Exhibit: _____
c. Are Liquidated Damages currently being assessed (yes/no): _____ If yes, please attach the
assessment as Exhibit: _____
9. Please state the Department’s determination from which this appeal is taken. NOTE: Attach a copy
of the Department document sent notifying you of the Department’s determination.
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