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Inspector General <br />California Department of Transportation <br />Financial Document Review (FDR) Request Form <br />• To be completed by Local Public Agencies (LPA) - one per contract. <br />• For new proposed Architectural & Engineering (A&E) consultant LPA contracts of $1 million or greater. <br />• For amendments, use only when there are additional subconsultants or changes in Indirect Cost Rate (ICR). <br />Email to: <br />conformance.review(adot.ca. gov Date: <br />California State Department of Transportation <br />Independent Office of Audits and Investigations Federal/State Project Number: <br />Attention: Financial Document Review Manager <br />Check one: <br />A&E Contract Number: <br />New Contract ❑ Amendment ❑ Other ❑ (describe) <br />Prime Consultant Full Legal Name: <br />Total Contract or Amended Amount of: <br />Project Description: <br />All Primes and Safe Harbor Rate (SHR) Applicants must be listed below. In addition, complete below for all <br />Sub-Consultant(s) with estimated contract costs of $500,000 and above on this contract. Sub-consultant(s) with <br />less than an estimated contract cost of $500,000 do not need to be included unless they are SHR applicants: <br />(Add pages if necessary.) <br />Consultant's Name: Estimated Contract Cost Category Caltrans ICR Acceptance <br />ID # (if available) <br />I verify we received financial documents from the prime and sub -consultants based on the requirements specified <br />in this form's Checklist seen on following page. <br />Name (Print): <br />Signature: <br />Name of Local Agency and Department: <br />Address: <br />Phone: <br />Email: <br />Title: <br />Financial Documen�Rte eC Requ�estlForm - Independent Office of Audits and investigationnss - Revviiseed 9/2022 7/18/2023 <br />