DGS-30-234
(Rev. 10/10)
CONTRACTOR’S CLAIM CERTIFICATION
Pursuant to Code of Virginia, I hereby certify that the contractual claim submitted in writing by ______(name of Contractor) to (name of public body) arising from the Project (Project name) in ______County, Virginia, including any and all statements and records submitted in support of such claim, is a true and accurate representation of the claim, additional costs and/or delays the Contractor incurred in the performance of the required contract work. I further certify that the claim is not the result of, or affected by, any act of collusion with another person engaged in the same line of business or commerce; or any act of fraud punishable under the Virginia Governmental Frauds Act, § 18.2-498.1, etseq. of the Code of Virginia. I understand that any statements made, and known to be false, shall be a violation of the Virginia Governmental Frauds Act, punishable as a Class 6 Felony. In addition, I understand that any claim submitted in violation of the Virginia Fraud Against Taxpayers Act, § 8.01-216.1, etseq. of the Code of Virginia shall be subject to the civil penalties provided therein.
(Contractor)
By:
As officer or duly appointed agent of (Contractor)
Title:
Date:
State Of:
City/County of ______, To-Wit:
I, the undersigned, a Notary Public in and for the City/ County and State aforesaid, do hereby certify that , whose name is signed to the foregoing instrument, bearing date of the ______day of ______, 20____ , has this day acknowledged the same before me in my City/ County and State aforesaid.
Given under my hand this ______day of ______, 20___ .
Notary Public:
My commission expires:
Claims submitted without thisCertification above shall not constitute a proper claim and, if not submitted with the Certification within the time required, shall be deemed to be waived.