HomeMy WebLinkAboutContract 44743-CO43 C4W 0'0(Lo
TEXAS DEPARTMENT OF TRANSPORTATION
CITY CHANGE ORDER NUMBER: 43
Third Party Funding Notification Sheet CITY
SECRETARY
E R��Y11fL1 r I.3_
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. 0902-48-539
Cky of Fort Worth
(Outside Entitys Legal Name) Project. BR 2006(132)
2.Type of outside funding agreement for this change: Highway. CS
❑ Existing ❑ Amended ❑ New County. Tarrant
[Check one]
District. 02-Fort Worth
3. Indicate the type and amount of funding:
Contract
E]Fixed Price(Lump Sum) (Estimated Amount 'l Number. 08133013
E] Actual Cost
(a) Contract Items(Bid items): $1,425.34 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
enw% Date 213117
TOTAL $1,425.34
By
CITYF FORT WORTH
APPRO L RECOMMENDED:
D: Typed/Prtnted Name Jay Chapa
4At, G-J, w Typed/Printed Title Assistant City Manager
Douglasiersig,P.E.
Director, ransportation/Public Vyrks Department
•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
of E&C charge. For a specific project,E&C rate(%)can be derived from the cost of"Engineering and Conlingendes•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 AgreemPnl. See Stand Alone Manual Notice 98-2 for Instructions. p
n
Funding for this Change Order has been arranged: .
V
Ca
YXOOT Ropresentethre Date
Typed/Printed Name:
TXDOT Form 2146•AFA(Rev.0912010)Page 1 of 1 Contract Compliance Manager: ..i4:
A�; i
B signing I acknowledge that I am the person responsible; , i
Y 8a 8 � P P ,��..-........
APPROVED AS TO FORM AND LEGALITY for the monitoring and administration of this contract,inoll[ Q
q . ensuring all performance and repo irem s.ri
%
{rti f
!� Douglas W.Black yy _
O m r I Assistant City Attorney I4ficme!'liffeiss,P.E. '
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