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HomeMy WebLinkAboutContract 43373-CO11 P . TEXAS DEPARTMENT OF TRANSPORTATION tj CITY CHANGE ORDER NUMBER: 11 Third Party Funding Notification Sheet CITY SE"RE7ARY CONTRACT NO. 143373-CO I I This form is used when the subject change order involves funding by a source other than TxDOT/U.S.DOT,and involves third parties who are providing funding under an Advance Funding Agreement or Donation Agreement. 1. Outside funding provided by: CCSJ: 0902-48-722 City of Fort Worth (Outside Entity's Legal Name) Project. STP 2012(777)MM 2.Type of outside funding agreement for this change: Highway: CS F,-/] Existing ❑ Amended ❑ New County: Tarrant [Check one I District: 02-Fort Worth 3. Indicate the type and amount of funding: Contract ❑Fixed Price (Lump Sum) (Estimated Amount ) Number. 11163008 0 Actual Cost (a) Contract Items(Bid Items): $16,945.71 Use as needed: I hereby acknowledge notification of the modifications (b) E&C*: (a)x = $0.00 covered by this Change Order. (c) Indirect Cost**: (a+ b)x = $0.00 enter% Date 8/23/49 TOTAL $16,945.71 BY - CITY OF FORT WORTH APPR a VAL RECOMM D: Typed/Printed Na Da' Burghdof� �(}RT/5► #' Typed/Printed Title Interim Assist; % William Johnson City Manage >' a Director,Transportat' n/Public Works Department LL.': ;t O The percentage(%)for E&C(Engineering and Contingencies)charges varies from project to project �, ��''••., depending on the contract amount of the project. Projects with higher contract amount will have the lower rate t�� of E&C charge. For a specific project, E&C rate(%)can be derived from the cost of"Engineering and Contingencies"in the"Estimated Cost"of the project. "Use the statewide district rate as established by Finance Division each year. This line 3(c)is for Service Project only, unless otherwise specified in the Advance Funding Agreement. See Stand Alone Manual Notice 98-2 for instructions. t Funding for this Change Order has been arranged: R TxDOT Representative Date ' Typed/Printed Name: TXDOT Form 2146-AFA(Rev.09/2010)Page 1 of 1 Contract Compliance Manager: By signing I acknowledge that I am the person responsibl ,.s UPIS TO FORM AND LEGALITY for the monitoring and administration of this contract, incl in , ensuring all performance and reporting requirements. Douglas W. Black � ���������� Assistant City Attorney Michael Weiss yy t U� Sr. Professional Engineer 0TY SECRETARY FT WORTH,TX ATTEST: Mary J. 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