Legal Claim Contract Claim Form

LEGAL CLAIM CONTRACT CLAIM FORM

This Legal Claim Contract Claim Form is made and entered into as of by and between Claimant Name: (hereinafter "Claimant") and Respondent Name: (hereinafter "Respondent").

RECITALS

WHEREAS, Claimant and Respondent are parties to a written agreement identified as Contract Reference: (the "Agreement"), dated ; and

WHEREAS, Claimant asserts that Respondent breached or otherwise failed to perform obligations under the Agreement resulting in monetary loss and other damages; and

WHEREAS, the parties desire to document the Claim details, the relief sought, and the procedures for resolution of the Claim in accordance with the terms set forth below.

NOW, THEREFORE, in consideration of the mutual covenants set forth herein, the parties agree as follows.

1. DEFINITIONS

For purposes of this Form, the following definitions apply: "Claim" means the asserted contractual or statutory right to recovery described in Section 2. "Claim Amount" means the principal amount claimed and any accrued interest, fees, and costs. "Supporting Documents" means the invoices, correspondence, contracts, and other documentary evidence attached in support of the Claim.

2. NATURE AND DETAILS OF CLAIM

Claim Description:

Date of Alleged Breach or Event Causing Claim:

3. CALCULATION OF DAMAGES

Claim Amount is calculated as follows: Principal damages plus contractual or statutory interest calculated from at a rate of compounded as specified under the Agreement or applicable law. Supporting calculations and a ledger itemization are attached as Supporting Documents.

4. SUPPORTING DOCUMENTS

The following documents are submitted in support of the Claim (check applicable boxes and attach copies):

Agreement or Contract
Invoices and Payment Records
Correspondence and Notices
Photographs or Physical Evidence
Other (describe below)

5. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants to the other that: (a) it has full corporate or individual authority to execute and deliver this Form and to perform its obligations hereunder; (b) the information provided in support of the Claim is true, complete and accurate to the best of the submitting party's knowledge; and (c) no material fact has been omitted that would render any representation herein misleading.

6. AUTHORIZATION AND RELEASE

By submitting this Form, Claimant authorizes Respondent and any designated agents or representatives to inspect and copy relevant records and authorizes third parties identified in the Supporting Documents to disclose records relevant to the Claim. Check to authorize settlement discussions with counsel or representatives:

7. CONFIDENTIALITY AND NON-ADMISSION

All communications, negotiations and any draft settlement terms relating to this Claim shall be without prejudice and shall not constitute an admission of liability by any party. Unless otherwise agreed in writing, the parties shall treat the existence and terms of any settlement discussions as confidential.

8. NOTICES

All notices required or permitted under this Form shall be in writing and addressed as follows:

9. RESOLUTION PROCEDURE

The parties agree to attempt in good faith to resolve the Claim through negotiation. If negotiation fails within thirty (30) days following delivery of this Form, the parties agree that the Claim shall proceed by the dispute resolution method specified in the Agreement. If the Agreement is silent, the parties agree to submit the Claim to mediation followed, if necessary, by litigation in the courts identified in Section 11.

10. REMEDIES CUMULATIVE

Except as otherwise provided by the Agreement, all remedies available under this Form, at law or in equity are cumulative and may be exercised concurrently or separately by the parties.

11. GOVERNING LAW; VENUE

This Form shall be governed by and construed in accordance with the laws of the state or jurisdiction identified below. The parties consent to exclusive jurisdiction and venue in the courts located in the jurisdiction specified.

12. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT; WAIVER

This Form constitutes the entire record of the parties' agreement with respect to the Claim and supersedes any prior oral or written understandings specifically related to the Claim. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall continue in full force and effect. Any amendment to this Form must be in writing signed by both parties. Failure to enforce any right or provision shall not constitute a waiver of such right or provision.

13. COUNTERPARTS

This Form may be executed in counterparts, each of which will be deemed an original, and all of which taken together will constitute one instrument. Facsimile or electronic copies of signatures shall be deemed originals for all purposes.

14. CERTIFICATION

The undersigned certify under penalty of perjury under the laws of the applicable jurisdiction that the information contained in this Form and the attached Supporting Documents is true and correct to the best of their knowledge and belief, and that they are authorized to submit this Claim on behalf of the party identified.

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