7-Change Order Form.pdf.pdf
PDF 201 KB Posted
- Attached to
- Kirby Street Pump Station #08 Rehabilitation
- Solicitation number
- IFB-26-00404
- Issued by
- Hillsborough County, Florida
About this file
This is a Change Order Form utilized by Hillsborough County, Florida for modifications to construction contracts. The form provides a standardized template for documenting authorized changes and modifications to existing contracts, including adjustments to contract sums, project timelines, and completion milestones. The document establishes a structured process requiring documentation of the original contract sum, net changes from previous change orders, the current contract sum prior to the change order, and the new contract sum following approval. The form accommodates three primary categories of changes: time modifications, extra work, and credits, with designated sections for describing the nature of changes, identifying cost impacts, and specifying reasons for modifications. The form requires execution by authorized representatives from both the contractor and Hillsborough County, including the Clerk of Circuit Court, Chair of the Board of County Commissioners, and approval from the County Attorney as to form and legal sufficiency.
The Change Order Form includes provisions for notarization of contractor acknowledgments and requires surety consent when applicable, with the surety acknowledging adjustments to performance and payment bonds in accordance with contract modifications. The contractor waives any claims to additional time extensions or monetary compensation beyond those specified in the change order document. The form is designed to ensure compliance with all applicable contract requirements and maintains the integrity of the original contract terms except where explicitly modified. This standardized form was last revised on January 29, 2025, and is applicable to the Kirby Street Pump Station #08 Rehabilitation project, a stormwater pump station construction project in Tampa, Florida with an estimated total project cost of $1,473,476.90 and a 10 percent Small Business Enterprise subcontractor participation goal.
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Text version
Revised 01.29.2025
HILLSBOROUGH COUNTY
CHANGE ORDER FORM
CONTRACT: CHANGE ORDER NO.:
BID NO:
CONTRACTOR: PROJECT NO:
CPA NO:
TIME CHANGE EXTRA WORK CREDIT OTHER
The Contractor is hereby authorized and directed to make the following changes and modifications to the aforesaid Contract in accordance with all requirements applicable thereto.
DESCRIPTION OF CHANGE:
COST
IMPACT
FINAL
COMPLETION
DAYS
REASON FOR CHANGE:
The original Contract Sum (TOTAL GMP) was . . . . . . . . . . . . $____________ Net change by previous Change Orders . . . . . . . . . . . . . . . . $____________ The Contract Sum prior to this Change Order was . . . . . . . . . . . . . $____________ The Contract Sum will be by this Change Order. . . . . . $ ____________ (increased, decreased or unchanged) The new Contract Sum including this Change Order will be . . . . . . . . . . $ ____________
The Final Completion Milestone prior to this Change Order was .
The time for Final Completion Milestone will be ______________ by __________( )days.
(extended, reduced or unchanged) The Final Milestone for this change order therefore is therefore
The Contractor waives any and all claims to additional time extension and/or additional monetary compensation resulting from these changes and all cost associated with the change order as herein addressed.
Excepting those terms and provisions conflicting with this Change Order which are hereby changed to conform hereto, the aforesaid Contract as amended by all previous change orders hereto is otherwise reaffirmed in its entirety.
IN WITNESS WHEREOF, this Change Order No. _______ to __________________________________ has been executed by the parties hereto or their duly authorized representatives.
ATTEST: VICTOR D. CRIST COUNTY: HILLSBOROUGH COUNTY FLORIDA
Clerk of Circuit Court
BY: BY:
Deputy Clerk Chair, Board of County Commissioners
BOCC Document Number Date of BOCC approval
ATTEST: CONTRACTOR:
BY:
Witness Authorized Signature (SEAL)
TITLE:
DATE:
BOCC Staff Approval Date
Department Fiscal Department Director Procurement County Attorney:
Approved as to Form and Legal Sufficiency
(ACKNOWLEDGMENT OF CONTRACTOR, IF A CORPORATION)
STATE OF )
COUNTY OF )
The foregoing instrument was acknowledged before me by means of physical presence or online notarization this day of , 20 , by ______________________ (Name of person) as____________________________ for ___________________________________________________.
(ie. Officer, attorney in fact) (Name of party on behalf of whom instrument was executed.)
(Signature of Notary Public)
(Print, Type, or Stamp Name of Notary Public)
Personally Known OR Produced Identification
Type of Identification Produced ______________________
(ACKNOWLEDGMENT OF CONTRACTOR, IF A PARTNERSHIP OR INDIVIDUAL)
STATE OF )
COUNTY OF )
The foregoing instrument was acknowledged before me by means of physical presence or online notarization this day of , 20 , by .
(Name of person acknowledging)
(Signature of Notary Public)
(Print, Type, or Stamp Name of Notary Public)
Personally Known OR Produced Identification
Type of Identification Produced ______________________
CONSENT OF SURETY TO CHANGE ORDER
CONTRACT TITLE:
CONTRACTOR (PRINCIPAL):
SURETY:
AGENT:
The SURETY does hereby acknowledge and agree to Change Order No. to the above referenced contract with Hillsborough County, the contract amount (increasing/decreasing) by $ , and/or extending the completion date by ( ) calendar days. The SURETY further acknowledges that the performance bond and/or payment bond furnished under the aforementioned contract is accordingly changed to reflect the change in contract amount, and/or time included in Change Order No. .
This Consent is dated this day of , 20 .
SURETY:
BY: (SEAL)
Authorized Signature
-OR-
BY: (SEAL)
As Attorney in Fact (Attach Power of Attorney)
Printed Name
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
The foregoing instrument was acknowledged before me by means of physical presence or online notarization this ___ day of ____________, 20___, __________________________ by (Name of person) ________________________ for _________________________________________________.
(ie. Officer, attorney in fact) (Name of party on behalf of whom instrument was executed.)
(Signature of Notary Public) (Print, Type, or Stamp Name of Notary Public)
Personally Know OR Produced Identification
Type of Identification Produced __________________
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