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FUEL COST ADJUSTMENT AFFIDAVIT <br /> North Dakota Department of Transportation, Construction Services <br /> SFN 58393(07-2008) <br /> Project Number <br /> The Contractor is not required to notify the Department at the time of submitting bids whether he will or will not participate <br /> in the fuel cost adjustment program. The Contractor shall return the affidavit on all Contracts with this Provision even if <br /> the Contractor elects not to participate. <br /> Check the box for each fuel type that has a fixed price. <br /> No adjustments in fuel price will be made for the boxes that are checked. <br /> Diesel ❑ Unleaded ❑ Burner Fuel <br /> Does your company elect to participate in a fuel adjustment for this contract for the fuels that do not have a fixed price? <br /> No adjustments in fuel prices will be made if No is checked. <br /> ❑ Yes El No <br /> If yes, provide the total dollars for each of the applicable fuels. <br /> Diesel (x) $ <br /> Unleaded (y) $ <br /> Burner Fuel (z) $ <br /> Sum (x+y+z) $ % of Original Contract Amount %" <br /> The sum of the x,y,and z may not exceed 15%of the original contract amount. <br /> Under the penalty of law for perjury of falsification, the undersigned, <br /> Name Pnnt � itle nn <br /> of -y.... 4- h v-coj 'E , . , here by certifies that the documentation is submitted in good <br /> Can tractor <br /> faith, that the information provided is accurate and complete to the best of their knowledge and belief, and that the <br /> monetary amount identified accurately reflects the cost for fuel, and that they are duly authorized to certify the above <br /> documentation on behalf of the company. <br /> I hereby agree that the Department or its authorized representative shall have the right to examine and copy all Contractor <br /> records, documents, work sheets, bid sheets and other data pertinent to the justification of the fuel costs shown above. <br /> Date 'Srgned <br /> State of ► 11t\~v'�� <br /> County of ::T. ''L \CL.L Q <br /> r�.. <br /> Subscribed and sworn to before me this day of \ \OS-01-\ o\ <br /> 4 <br /> "MFTKREMPLE ----Signature of otary Public <br /> NOTARY PUBLIC—MINNESOTA <br /> My Commission Expires JAN 31 2015 _ <br /> +r,r �„„�. .., + My Commission Expires p5 <br />