OAH-35 SHORT TITLE CASE NO. PWCA COMPLAINT CLAIM FORM--CLAIM ITEM NO. _____ (Number each claim item separately. Use a Claim Form for each separate claim dispute and number each using an appropriate numbering system.) 1. 2. Petitioner alleges this claim item is for the sum of $ ___________________ In accordance with Public Contract Code § 10240.11 and 1 CCR Sec. 1351(b)*, this specific claim item was previously presented to the Respondent on (date) _____________________________ and arises from: (check all that apply) a. b. c. d. e. f. g. A breach of the contract provisions described in item 4 below. An act or failure to act of the respondent that violated the contract as described in item 4 below. A defect in the specific plans or specifications described in item 4 below. A differing site condition described in item 4 below. A failure to pay for contract item work described in item 4 below. A failure to pay for extra work ordered by respondent as described in item 4 below. Other causes described in item 4 below. 3. A Notice of Potential Claim a. was timely presented to the Respondent for this claim item on (date) ________________________. b. was not required for this claim item by the contract. c. was not timely presented to the Respondent for this claim item (explain below). In ordinary and concise language, provide a statement of this claim item, alleging its basis with appropriate references to each party's obligations under the Contract. [Use additional pages if necessary. 1 CCR Sec. 1351(b)(7)*] 4. a. Additional pages for this Claim Item are attached *Legal references are to the Public Contract Code and California Code of Regulations, Title 1, Division 2, Chapter 4 (PWCA) Form approved for optional use PWCA -002-2011 PWCA Arbitration Program OAH-35 CLAIM FORM - CONTRACT Claim Item No. _____, Page 1 of ____ American LegalNet, Inc. www.FormsWorkFlow.com