HomeMy WebLinkAboutContract 43373-CO2 TEXAS DEPARTMENT OF TRANSPORTATION
CITY CHANGE ORDER NUMBER: 2
Third Party Funding Notification Sheet MYSECRETARY
CONTRACT NO._4 33,1.5-cz;t
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
Q Existing ❑ Amended ❑ New County: Tarrant
[Check one]
District. 02-Fort Worth
3. Indicate the type and amount of funding:
Contract
❑Fixed Price(Lump Sum) (Estimated Amount ) Number. 11163008
Actual Cost
(a) Contract Items(Bid Items): $8,100.00 Use as needed.
1 herby 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 611W7
TOTAL $8,100.00 r�
By
CITY OF FORT WORTH
AP17L RECOMMENDED: Typed/Printed Name Jay Chapa
s , (.J Typed/Printed Title Assistant Cltx,mb, e�
Douglas .Wiersig,P.E.
Director, ransportation/Public 1vorks Department
•The percentage(%)for E&C(Engineering and Contingencies)charges varies from project to project X
depending on the contract amount of the project.Projects with higher contract amount will have the lower rate two ss
of E&C charge. For a specific project,E&C rate(%)can be derived from the cost of"Engineering and Contingencies"111 '.• _
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.
Funding for this Changs Order has been arranged:
V
02� V
F�of E�A�WDA E TxDOT RepreseMathre Date
Typed/Printed Name:
JD
ti
TXDOT Form 2146-AFA(Rev.09/2010)Page 1 of 1 Contract Compliance Manager:
By signing I acknowledge that I am the person responsible ��++
APPROVED AS TO FORM AND LEGALITY for the monitoring and administration of this contract,including rG
ensuring all performance and reporting requirements.
Douglas W.Black EFT. WORTH,
ECO41)
Assistant City Attorney Michael Weiss TARY
Sr.Professional Engineer TX
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