Attorney, or Party without Attorney (Name, State Bar No., and address) OAH-34 FOR ADMINISTRATIVE USE ONLY Telephone No: Email Address: Attorney For (Name): Fax No: Office of Administrative Hearings ("OAH") Public Works Contract Arbitration ("PWCA") 2349 Gateway Oaks Drive, Suite 200 Sacramento, CA 95833-4231 COMPLAINT CROSS COMPLAINT Petitioner: Respondent: AMENDED COMPLAINT No. ____ AMENDED CROSS-COMPLAINT No. ____ Interested Party: Does No. 1 to No. _____ Public Works Contract No. (if applicable) OAH CASE No. If this form is used as a cross-complaint, Petitioner means Cross-complainant and Respondent means Cross-Respondent 1. Petitioner alleges causes of action against Respondent(s) (include names and addresses): 2. Petitioner is a: Competent adult Corporation qualified to do business in California Petitioner's contract status was a : Prime contractor Department or Public Agency Subcontractor, or Other (specify) An unincorporated entity (describe) : Other (specify): Respondent's contract status was a : Prime contractor Department or Public Agency Subcontractor, or Other (specify) 3. 4. Petitioner: Has complied with the fictitious business name laws and is doing business under the fictitious business name of (specify) : Has complied with all licensing requirements as a licensed (specify) : Joinder of the following Interested Parties is requested: (list name and address of Interested Parties) A. Each Respondent and Interested Party is a natural person. B. Interested Party (specify) ______________________________________________ is a: Government entity Corporation Unincorporated entity (describe) Other (describe): C. The true names and capacities of Respondents sued as Does are unknown to Petitioner. 5. 6. Form approved for optional use PWCA Arbitration Program OAH-34 COMPLAINT - CONTRACT Page 1 of 2 1 CCR Sec. 1350, 1351 American LegalNet, Inc. www.FormsWorkFlow.com PWCA-001 SHORT TITLE CASE NO. 7. This Complaint is timely because: (Check either box A. or B.) A. This Complaint is timely under Public Contract Code § 10240.1 because it was filed not later than 90 days after Petitioner's receipt of the Final Written Decision of the department, which occurred on ___________________, 20___ and is included here as "Attachment 7." B. This Complaint is timely under Public Contract Code § 10240.2 because (also check one box below) : Petitioner has not received a Final Written Decision of the department, but more than 240 days have elapsed since acceptance of the contract work on (date) _________________________ and "Attachment 7" is a copy of the contract acceptance document. Petitioner has not received a Final Written Decision of the department, and the contract work was not accepted, but Petitioner is entitled to file for arbitration because: (explain and use "Attachment 7") 8. Petitioner Has complied with all administrative procedures of the contract (Public Contract Code § 10240.2). Has not complied with all administrative procedures of the contract because (explain, and include "Attachment 8" if necessary) 9. The claim or claims : a. Were previously presented to the Public Agency for decision in compliance with all Contract claims procedures. [Public Contract Code § 10240.2; 1 CCR Sec. 1351(b)(6)] b. Were not previously presented to the Public Agency for decision because: (explain, and include "Attachment 9" if necessary) 10. Submit a PWCA CLAIM FORM for each separate Claim (PWCA Form 002) or Claim Item in this Complaint. There are a total of ____ claim forms in this complaint, and the total dollar amount requested in arbitration is $ __________________________, before interest, costs and such further amounts as the arbitrator may determine. 11. This pleading, including its attachments and exhibits, consists of the following number of pages: _____ Verification I, (print name) _______________________________________________ , declare under penalty of perjury under the laws of the State of California that I am an authorized representative of the Petitioner, I have read the facts and contents of all matters herein, and they are true of my own knowledge, except those that are stated on information and belief, and as to those I believe them to be true. Signed __________________________________ on____________________ 20___, at __________________________, California. (circle status) officer/director/owner/authorized employee/legal representative *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 Arbitration Program OAH-34 COMPLAINT - CONTRACT Page 2 of 2 1 CCR Sec. 1350, 1351 American LegalNet, Inc. www.FormsWorkFlow.com