Fillable Statement of Claim Office of the Chief Administrative Law Judge

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Statement of Claim Office of the Chief Administrative Law Judge

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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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):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
10. Please state the reason(s) why you disagree with the Department’s determination set forth in No. 9
above. NOTE: Attach a copy of the document(s) you rely on to support your claim.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
11. Please state the provisions of the contract that govern the nature of your appeal. NOTE: § 7.16
applies to most appeals, please indicate all special provision(s) or contract specification(s) relevant
to support your appeal.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
12. Please state the law(s) or regulation(s) that govern the appeal.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
13. Print the Name of the person managing this appeal: ______________________________________
14. Contact Number: ( _____ )______—_______
Contractor’s signature or signature of authorized attorney:
Date: __________ ________________________________________________
**Please take the time to carefully examine the requirements of this form. Each field must be
fully and properly completed. Failure to comply with the requirements of this Statement of
Claim will result in the delay or potential dismissal of the claim. **
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Statement of Claim Office of the Chief Administrative Law Judge

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Completed 10 May 2020

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