252761MN_Change_Order_Form.pdf

County Change Order Request Form

County’s Designated Agent for this Project:

Name: Click or tap here to enter text. Position: Click or tap here to enter text.

Address: Click or tap here to enter text.

Phone: Click or tap here to enter text. Email: Click or tap here to enter text.

Instructions: This form is used by the County’s Designated Agent for ALL Change Order Requests. Each step must be completed in its entirety and stored in the County’s current Project Management Information System.

No Work associated with this Request is to be started until written County Approval, as described herein, is given.

A request for a Change Order price quote resulting in a Contract Modification must be processed through either an IFCA or a Contract Amendment, depending on amount of the price quote and the County’s Designated Agent’s approval authority.

IFCA: A Change Order price quote resulting in a Contract Modification that does not increase the monetary amount of the Contract. An IFCA shall only be initiated by the County Designated Agent set forth herein after completion of all steps in this Change Order Request Form.

Contract Amendment A Change Order price quote resulting in a Contract Modification that increases the Contract not-to-exceed amount.

A Contract Amendment requires approval by the appropriate delegated authority to authorize the expenditure of such Change Order. See Res. No. 2022-152 and the Procurement Manual, as amended, for further details. Change Order Requests requiring a Contract Amendment shall only be issued by the appropriate delegated authority. If funds have not been appropriated by the Board of County Commissioners, a Change Order Request shall only be issued by the Board.

Step 1: Request

The County Designated Agent requests a price quote to change the scope of the Project and directs the responsible engineer/architect to complete documentation supporting the request using Form for Step 1 of this form.

Step 2: Contractor Cost Proposal

Instructions (cont’d)

Upon receiving a County-issued Change Order Request Form for Step 1, the Contractor shall submit a written price quote on the Form for Step 2 to the County Designated Agent listed above and must be signed and dated by the Contractor’s authorized agent. Price quotes not in conformance with the above shall not meet the contract requirements for Change Orders.

Step 3: Approval or Denial to be filled out by County’s Designated Agent on the Form for Step 2 and returned to Contractor within 35 days of receipt of price quote

Upon the County Designated Agent’s receipt of Contractor’s price quote, County Designated Agent will review the price quote and, within 35 days after receipt of such quote, send written notice to Contractor of whether the County approves or denies the price quote. If the price quote is denied, the denial notice will specify the deficiency and actions necessary to remedy the deficiency.

A price quote shall be denied as deficient if the price quote is above the Contract amount, more than the remaining contingency, above the budgeted funds appropriated for the Project, or above the County Designated Agent’s approval authority. Additionally, the County Designated Agent shall have discretion to deny the price quote for other reasons that are in the interests of the Project and County.

Step 4. Processing of approved Change Agreement

If the price quote is approved by the County’s Designated Agent who is authorized to approve such expenditure, an Interim Field Change Agreement (IFCA) will be processed for the additional work reflected in the approved Change Order Request to begin. No work is to begin until the IFCA is completed.

Rights Reserved

If the price quote is denied, the County reserves the right to re-issue a change order request for a new price quote at a later date by written notification from the County representative who has the signature authority for the relevant monetary amounts.

Nothing herein shall change or waive the County’s rights set forth in the other provisions of the Contract.

In the event s. 218.755, F.S., is determined to be invalid by a court of competent jurisdiction, the statutory requirements as set forth above shall be null and void.

FORM STEP 1 - Request

CHANGE ORDER REQUEST NO.: COR- enter COR Number

PROJECT NAME: Click or tap here to enter text.

CIP PROJECT NO.: Click or tap here to enter text.

PO NO. Click or tap here to enter text.

CONTRACT NO.: Click or tap here to enter text.

DATE: Click or tap here to enter text.

AOR/EOR Firm Name

NAME: Representative Name

TITLE: Click or tap here to enter text.

EMAIL: Click or tap here to enter text.

PHONE: Click or tap here to enter text.

THIS IS NOT A CHANGE ORDER, INTERIM FIELD CHANGE AGREEMENT (IFCA) OR A

DIRECTION TO PROCEED WITH THE WORK DESCRIBED IN THE DESCRIPTION.

The Architect or Engineer of Record has provided the following to be used in the change order cost proposal.

<<Note to A/E: COR may include multiple items. Add to section below as needed.>>

COR Item No. Click or tap here to enter No. For: Click or tap here to enter COR Description.

REASON FOR REQUEST: Click or tap here to enter text.

PROPOSED CHANGES: Click or tap here to enter text.

<<Note to A/E: Reference specific edits to contract documents and attach all documents. Use DRAWING and/or SPECIFICATIONS sections as needed.>>

DRAWINGS:

1. Prof. Discipline Sheet Sheet Number Revision number dated Revision Date Brief description of changes included on sheet

2. Prof. Discipline Sheet Sheet Number Revision number dated Revision Date Brief description of changes to spec section

SPECIFICATIONS:

3. Specifications Section Section Number – Section Name dated Revision Date

ATTACHMENTS:

FORM STEP 1 – Request (cont’d)

1. Click or tap here to enter text.

2. Click or tap here to enter text.

3. Click or tap here to enter text.

Printed name of AOR/EOR: Click or tap here to enter text.

Signature: _____________________ Date: ________

Printed name of County Designated Agent: Click or tap here to enter text.

Signature: _____________________ Date: ________

[End of FORM - STEP 1]

Remainder of page intentionally left blank

FORM STEP 2 – Contractor’s Proposal

CHANGE ORDER REQUEST NO.: COR- enter COR Number

CONTRACTOR Firm Name

NAME: Contractor’s Authorized Agent Name

TITLE: Click or tap here to enter text.

EMAIL: Click or tap here to enter text.

PHONE: Click or tap here to enter text.

DESCRIPTION:

1. Contractor’s price quote total: Click or tap here to enter text.

2. Additional contract days requested: Click or tap here to enter text.

3. Additional information related to the price quote:

Click or tap here to enter text.

4. Attachments:

a. Click or tap here to enter text.

b. Click or tap here to enter text.

c. Click or tap here to enter text.

Submittal Date of Price Quote: Click to enter Date

Approval/Denial Date (35 calendar days from Submittal): Click to enter Date

Price Quote valid thru Date (Optional): Click to enter Date or N/A

Contractors Authorized Agent Signature:

[End of FORM - STEP 2]

FORM STEP 3 – Approval or Denial

CHANGE ORDER REQUEST NO.: COR- Click to enter COR Number

A. The Designated Agent recommends approval of the Contractor’s Proposal:

☐ Recommend Approval – IFCA will be initiated for approval and execution

B. Designated Agent denies the Contractor’s Proposal and specifies the following deficiencies:

☐ Denied – Requires a Contract Amendment and Board approval. Request requires a Contract Amendment or no other delegated authority exists. Item may be brought before Board to consider issuing a Change Order.

☐ Denied – Price quote is too expensive

☐ Denied – Other reason(s) for deficiency: Click or tap here to enter text.

C. If denied, the Designated Agent identifies the following possible actions to remedy deficiencies:

☐ Designated Agent will request preparation of a draft Contract Amendment incorporating the Contractor’s Proposal to be brought before the Board for consideration.

The anticipated Board date is before the Price Quote valid thru Date identified by the Contractor on the Step 2 Form.

☐ Contractor’s Proposal may be adjusted and resubmitted to reduce price.

☐ Other means to remedy: Click or tap here to enter text.

Printed name of County Designated Agent: Click or tap here to enter text.

Signature: _____________________

Notification Date of Approval or Denial: Click or tap here to enter text.

[End of FORM - STEP 3]