Form 517046 (02-20)

Transfer of Jurisdiction Checklist

LPA Name:            

Project Description including route and starting and ending roads:      

Letting Date (if known):       District No.:      

The following checklist is to assist in preparing a Transfer of Jurisdiction Agreement with a Local Public Agency (LPA) for
a DOT administered primary road project. The checklist addresses the items where most questions arise during the
agreement preparation process.

State transfers jurisdiction

LPA transfers jurisdiction
Transfer includes Leases
Transfer includes Right of Way
Transfer includes Bridges, if yes (FHWA Bridge No(s))
Segment is being transferred in its present condition
DOT is performing repairs prior to transfer (describe repairs and the area of the segment)
DOT is making lump sum payment prior to transfer in lieu of repairs (amount to be given and what the cost
represents, full-width HMA resurface, etc)
DOT is making installment payments prior to transfer in lieu of repairs (total dollar amount and dollar amount of the 3
installments)

EXHIBITS
Map showing the segment to be transferred