BOR Contract _ Forms.pdf

Forms 1

FORMS INDEX:

Performance Bond Payment Bond Contractor Affidavit Subcontractor Affidavit Certificate of Liability Insurance Change Order Forms Application for Payment Form Subcontractor Retainage Release Certification

Forms 2

PERFORMANCE BOND

Bond No.

Project No. Project Number

KNOW ALL MEN BY THESE PRESENTS:

That ___________________________________________________________ as principal (hereinafter referred to (Legal Name and Address of the Contractor) as "Contractor"), and ________________________________________________ as surety (hereinafter referred to (Legal Title and Address of Surety) as "Surety"), are held and firmly bound unto the Board of Regents of the University System of Georgia as Obligee (hereinafter referred to as "Owner") in the amount of and No/100 Dollars ($ .00), to which payment Contractor and Surety bind Themselves, their heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.

WHEREAS, the above bounden Principal has entered into a contract with the Owner bearing date of Month, Day, Year for: Project Number and Description, Institution Name, City, State in accordance with drawings and specifications prepared by: LEGAL DP Firm Name which said contract is incorporated herein by reference and made a part hereof, and is hereinafter referred to as the Contract.

NOW THEREFORE, THE CONDITION OF THIS OBLIGATION is such that, if the Contractor shall promptly and faithfully perform and comply with the terms and conditions of said contract; and shall indemnify and save harmless the Owner against and from all cost, expenses, damages, injury or loss to which said Owner may be subjected by reason of any wrongdoing, including patent infringement, misconduct, want of care or skill, default or failure of performance on the part of said Principal, his agents, subcontractors or employees, in the execution or performance of said contract, then this obligation shall be null and void; otherwise it shall remain in full force and effect.

(1) The said Surety to this bond, for value received, hereby stipulates and agrees that no change or changes, extension of time or extensions of time, alteration or alterations or addition or additions to the terms of the contract, or to the work to be performed thereunder, or the specifications or drawings accompanying same, or the exercise of the Owner’s right to do work pursuant to Articles 1.3.7, 1.7.8, or 5.3.5, or Paragraphs 3.4.1.4 or 5.3.2.3, shall in any way affect its obligation on this bond, and it does hereby waive notice of any such change or changes, extension of time or extensions of time, alteration or alterations or addition or additions to the terms of the contract or to the Work or to the specifications or drawings. In addition, the Surety to this bond, for value received, hereby agrees to the provisions of Article 1.5.1, including Paragraph 1.5.1.3 for increases in the penal amount of this bond, and waives notice from the Owner of any such changes.

(2) If pursuant to the Contract Documents the Contractor shall be declared in default by the Owner under the aforesaid Contract and the Owner has terminated the Contractor’s right to complete the Contract, the Surety shall promptly perform this bond agreement in accordance with its terms and conditions. If Surety chooses to investigate, Owner shall cooperate with the Surety in its investigation and shall make all public project records available for inspection by Surety at no cost to Owner. It shall be the duty of the Surety to give an unequivocal notice in writing to the Owner, within twenty-five (25) days after receipt of such a declaration of default, of the Surety's election to either remedy the default or defaults promptly or to perform the Contract promptly, time being of the essence. In said notice of election, the Surety shall indicate the date on which the remedy or performance will commence, and it shall then be the duty of the Surety to give prompt notice in writing to the Owner immediately upon completion of (a) the remedy and/or correction of each default, (b) the remedy and/or correction or each item of condemned work, (c) the furnishing of each omitted item of work, and (d) the performance of the contract. The Surety shall not assert its Principal as justification for its failure to give notice of election or for its failure to promptly remedy the default or defaults or perform the Contract.

(3) It is expressly agreed by the Principal and the Surety that the Owner, if he desires to do so, is at liberty to make inquiries at any time of subcontractors, laborers, materialmen, or other parties concerning the status of payments for labor, materials, or services furnished in the prosecution of the work.

(4) No right of action shall accrue on this bond to or for the use of any person or corporation other than the Owner named herein or the legal successors of the Owner.

Forms 3

(5) For the purposes of this bond, the name and address of the responsible official of the Surety’s claims department, to whom correspondence and telecommunications may be addressed and/or with whom business concerning this bond may be conducted will be as follows:

NAME

TITLE __________________________________________________________________

ADDRESS

CITY STATE ZIP CODE

TELEPHONE

(6) Further, this bond shall be the Performance Bond furnished under O.C.G.A. §§ 13-10-2, 13-10-20 and shall be subject to increase in the penal amount of the bond pursuant to such statutes and Article 1.5.1 of the Contract.

(7) No action can be instituted on this bond after one year from the date of Final Completion as determined pursuant to Article 6.2.2.

SIGNED AND SEALED THIS ___________ DAY OF __________________________, 20_____.

ATTEST: (NAME OF Contractor)

By Secretary(*) President

(SURETY) (*)(*)

(TITLE)

(*) Please apply seal of Corporation over Secretary’s Signature.

(*)(*) Please apply seal of Surety and arrange for countersignature by a “Georgia Licensed Agent” of Surety pursuant to O.C.G.A. §33-23-5. Kindly show title of the aforesaid agent as “Georgia Licensed Agent.”

(*) Attach Power of Attorney

Forms 4

PAYMENT BOND

Bond No.

Project No. Project Number

KNOW ALL MEN BY THESE PRESENTS:

That____________________________________________________________ as Principal (hereinafter referred to as the (Legal Title and Address of the Contractor)

"Principal") and ____________________________________________________________ as Surety (hereinafter referred ( Legal Name and Address of the Surety) to as "Surety"), are held and firmly bound unto the BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA as Obligee (hereinafter referred to as "Owner") for the use and benefit of claimants defined, hereinafter in the amount of Dollars ($ )to which payment Principal and Surety bind themselves, their heirs, executors, administrators, successors and assigns jointly and severally, firmly by these presents.

WHEREAS, the above bounden Principal has entered into a contract with Owner dated Month, Day, Yearfor Project Number and Description, Institution Name, City, State in accordance with the drawings and specifications prepared by: LEGAL DP Firm Name which contract is incorporated herein by reference and made a part hereof, and is hereinafter referred to as the Contract.

NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION is such that if the Principal shall promptly make payment to all claimants as hereinafter defined, for all labor and materials supplied in the prosecution of the work provided for in said Contract, then this obligation shall be void, otherwise it shall remain in full force and effect subject, however, to the following conditions:

(1) The said Surety to this bond, for value received, hereby stipulates and agrees that no change or changes, extension of time or extensions of time, alteration or alterations or addition or additions to the terms of the contract or to the work to be performed thereunder, or the specifications or drawings accompanying same, or the exercise of the Owner’s right to do work pursuant to Articles 1.3.7,1.7.8 or 5.3.5 or Paragraphs 3.4.1.4 or 5.3.2.3, shall in any way affect its obligation on this bond, and it does hereby waive notice of any such change or changes, extension of time or extensions of time, alteration or alterations or addition or additions to the terms of the contract or to the Work or to the specifications or drawings. In addition, the Surety to this bond, for value received, hereby agrees to the provisions of Article 1.5.1, including Paragraph 1.5.1.3, for increases in the penal amount of this bond and waives notice from the Owner of any such changes.

(2) A claimant is defined as any subcontractor and any person supplying labor, materials, machinery, or equipment in the prosecution of the work provided for in said contract.

(3) Every person entitled to the protection hereunder and who has not been paid in full for labor or materials furnished in the prosecution of the work referred to in said bond before the expiration of a period of ninety (90) days after the day on which the last of the labor was done or performed by him, or materials or equipment or machinery was furnished or supplied by him for which claim is made, shall have the right to sue on such payment bond for the amount, or the balance thereof, unpaid at the time of the commencement of such action and to prosecute such action to final execution and judgment for the sum or sums due him, provided, however, that any person having direct contractual relationship with a subcontractor, but no contractual relationship express or implied with the Contractor furnishing said payment bond shall have (a) given written notice to said Contractor within ninety (90) days from the day on which such person did or performed the last of the labor, or furnished the last of the materials or machinery or equipment for which such claim is made stating with substantial accuracy the amount claimed and the name of the party to whom the materials were furnished or supplied or for whom the labor was performed or done; and (b) if the Contractor has filed a Notice of Commencement in accordance with the requirements of O.C.G.A. §13-10-62 and Articles 4.3.2 of the contract, given to said contractor a written Notice to Contractor within 30 days from the filing of the Notice of Commencement or 30 days following the first delivery of labor, materials, machinery or equipment, whichever is later, setting forth:

A) The name, address, and telephone number of the person providing labor, material, machinery, or equipment;

B) The name and address of each person at whose instance the labor, material, machinery or equipment is being furnished;

C) The name and the location of the public work; and

D) A description of the labor, material, machinery, or equipment being provided and, if known, the contract price or anticipated value of the labor, material, machinery, or equipment to be provided or the amount claimed to be due, if any.

It is provided further that nothing contained herein shall limit the right of action to said 90-day period. Notice may be served by the depositing of a notice, certified mail, postage paid, duly addressed to the Contractor at any place he maintains an office or conducts his business, or his residence, in any post office or branch post office or any letter box under the control of the Post Office Department or notice may be served by statutory mail pursuant to O.C.G.A. §9-10-12 or in any manner in which the sheriffs of Georgia are authorized by law to serve summons or process. Every suit instituted under this section shall be brought in the name of the claimant without Owner being made a party thereof. The official who has custody of said bond is authorized and directed to furnish, to any person making application thereof who submits an affidavit that he has supplied labor or materials for such work and payment therefore has not been made, or that he is being sued on any such bond, a copy of such bond and the contract for which it was given, certified, by the official who has custody of said bond and contract shall be admitted in evidence without further proof. Applicants shall pay for such certified statements and such fees as the official fixes to cover the cost of preparation thereof, but in no case shall the fixed fee exceed the fees that the clerks of the superior courts are permitted to charge for similar copies.

Forms 5

(4) It is expressly agreed by the Principal and the Surety that the Owner, if he desires to do so, is at liberty to make inquiries at any time of subcontractors, laborers, materialmen, or other parties concerning the status of payments for labor, materials, or services furnished in the prosecution of the work.

(5) For the purposes of this bond, the name and address of the responsible official of the Surety’s claims department, to whom correspondence and telecommunications may be addressed and/or with whom business concerning this bond may be conducted will be as follows:

NAME

TITLE __________________________________________________________________

ADDRESS

CITY STATE ZIP CODE

TELEPHONE

(6) Further, this bond shall be the Payment Bond furnished under O.C.G.A. §§ 13-10-1, 13-10-60 et seq. and shall be subject to increase in the penal amount of the bond pursuant to such statutes and Article 1.5.1 of the Contract.

(7) No action can be instituted on this bond after one year from the date of Final Completion as determined pursuant to Article 6.2.2.

SIGNED AND SEALED THIS ___________ DAY OF __________________________, 20_____.

ATTEST: (NAME OF Contractor)

By Secretary(*) President

(SURETY) (*)(*)

(TITLE)

(*) Please apply seal of Corporation over Secretary’s Signature.

(*)(*) Please apply seal of Surety and arrange for countersignature by a “Georgia Licensed Agent” of Surety pursuant to O.C.G.A.

§33-23-5. Kindly show title of the aforesaid agent as “Georgia Licensed Agent.”

(*) Attach Power of Attorney

Forms 7

Contractor Affidavit under O.C.G.A. § 13-10-91(b)(1)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of Board of Regents of the University System of Georgia for the use and benefit of Institution Name, Using Agency (public employer) has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number

Date of Authorization

Name of Contractor

Project Number and Description Name of Project

Board of Regents of the University System of Georgia For the use and benefit of Institution Name Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ______, ___, 20__ in _____(city), ______(state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE ______ DAY OF ______________,20__.

NOTARY PUBLIC

My Commission Expires:

Forms 8

Subcontractor Affidavit under O.C.G.A. § 13-10-91(b)(3)

By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with (name of contractor) on behalf of Board of Regents of the University System of Georgia for the use and benefit of Institution Name, Using Agency (public employer) has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the subcontractor with the information required by O.C.G.A. § 13-10-91(b). Additionally, the undersigned subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to the contractor within five business days of receipt. If the undersigned subcontractor receives notice that a sub-subcontractor has received an affidavit from any other contracted sub-subcontractor, the undersigned subcontractor must forward, within five business days of receipt, a copy of the notice to the contractor. Subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number

Date of Authorization

Name of Subcontractor

Project Number and Description Name of Project

Board of Regents of the University System of Georgia For the use and benefit of Institution Name Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ______, ___, 20__ in _____(city), ______(state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE ______ DAY OF ______________,20__.

NOTARY PUBLIC

Forms 9

Sub-subcontractor Affidavit under O.C.G.A. § 13-10-91(b)(4)

By executing this affidavit, the undersigned sub-subcontractor verifies its compliance with O.C.G.A. § 13-10- 91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract for (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract) and

(name of contractor) on behalf of Board of Regents of the University System of Georgia for the use and benefit of Institution Name, Using Agency (public employer) has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned sub-subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned sub-subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the sub-subcontractor with the information required by O.C.G.A. § 13-10-91(b). The undersigned sub-subcontractor shall submit, at the time of such contract, this affidavit to

(name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract). Additionally, the undersigned sub-subcontractor will forward notice of the receipt of any affidavit from a sub-subcontractor to (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract). Sub-subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number

Date of Authorization

Name of Sub-subcontractor

Project Number and Description Name of Project

Board of Regents of the University System of Georgia For the use and benefit of Institution Name Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ______, ___, 20__ in _____(city), ______(state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE ______ DAY OF ______________,20__.

NOTARY PUBLIC

Forms 10

THIS FORM IS FOR OPTIONAL USE TO RELEASE TO THE CONTRACTOR FUNDS WITHHELD FROM A PAY APPLICATION IN THE EVENT A

SUBCONTRACTOR FILES A CLAIM AGAINST THE CONTRACT BALANCE HELD BY THE OWNER THAT REMAINS UNRESOLVED. THIS IS A SUBORDINATE

DOCUMENT TO THE PAYMENT BOND FOR THE PROJECT, AND IS CALCULATED AGAINST THE PENAL AMOUNT OF THAT PAYMENT BOND. THERE

ARE OTHER METHODS THAT MAY BE USED TO REMEDY SUCH SITUATIONS, HOWEVER, THIS FORM IS EFFECTIVE WHEN NONE OF THE PARTIES

ARE ABLE TO REACH AGREEMENT UPON THE CLAIM.

CHANGE ORDER FORMAT

(Lump Sum)

CHANGE ORDER No. _______

Project Name: ____________________________ Project Number: __________________________

Owner

1. Submission of this Change Order for consideration was authorized by letter from the Owner, dated , 20__, Incumbrance Record No. .

2. The changes hereinafter described are applicable to the Contract for the construction of the above-referenced Project and amend the Contract Documents.

3. Description of Change:

4. This Change Order is deemed necessary and originated with the (Design Professional) (Owner) (Contractor) (Using Agency). (Indicate applicable entity.)

5. This Change Order is necessary to:

6. The amount of the Change Order was determined by:

NOTE TO DESIGN PROFESSIONAL:

Please prepare each Change Order in the form and wording given below, deleting inapplicable wording and adding such explanations as may be necessary. The wording in Paragraph 11 may not be changed or altered in any way by either the Design Professional or the Contractor. Send four copies, signed by you and the Contractor, to the Owner. Do not forward a Change Order unless it is accompanied by a breakdown which has been certified by the Contract Compliance Specialist and Program Manager (if applicable).

Note to Design Professional:

Please leave the Change Order number blank. The Owner will assign a number.

Choose one:

a. Estimate and acceptance in lump sum.

b. Unit prices stated in contract or subsequently agreed upon.

c. Cost and percentage as described in general conditions.

Note to Design Professional:: No Change Order should be forwarded unless you have been furnished with a letter from the Owner authorizing same.

Note to Design Professional: Be sure to give a complete statement describing the changes in the work, including the specifications. If drawings are necessary, refer to them by date, etc., and state they are made a part of the Change Order. Copy of drawings should be attached to the Change Order.

Note to Design Professional: Give a complete description of conditions which necessitate the change.

7. A memorandum is attached showing cost breakdown of labor and materials by unit and quantities as prepared by the Contractor and checked by the Contract Compliance Specialist and Program Manager (if any).

8. We have verified the quantity and quality of all materials shown on the memorandum. We have verified that all prices are reasonable and do not exceed current costs for like services or materials, and we have verified that the quality of the materials meets the requirements of the Contract Documents.

9. The contractor shall be allowed additional calendar days for completion. The Material Completion and Occupancy Date is: __________________ .

10. The Contract Sum shall be (increased) (decreased) by $ _________________ on account of this change.

11. The payment and extension of time, if any, provided by this Change Order constitutes compensation in full to the Contractor and its Subcontractors, Suppliers, and Trade Contractors for all costs and markups, directly and indirectly attributable to the changes ordered herein, and for all delays or time related costs thereto and for any acceleration costs for performance of changes within the time stated and to be completed by the Material Completion and Occupancy Date and for any claims related thereto against the Owner and the Design Professional, and design consultants.

APPROVED AND AGREED BY CONTRACTOR: RECOMMENDED FOR OWNER'S ACCEPTANCE

LEGAL GC Firm Name DESIGN PROFESSIONAL: LEGAL DP Firm Name

By: By:

(Print Name/Title) (Print Name/Title)

Date approved by Contractor: Date approved by Design Professional:

APPROVED AND AGREED BY USING AGENCY: APPROVED AND AGREED BY OWNER:

INSTITUTION NAME BOARD OF REGENTS OF THE UNIVERSITY

By: By:

(Print Name/Title) (Print Name/Title)

Date approved by Using Agency: Date approved by Owner:

Note to Design Professional: Please insert the number of additional Days allowed and the new Material Completion and Occupancy Date, or, if no additional time is allowed, insert “0” for the Days and “No Change” for the date.

Note to Design Professional: Please observe that verification of quantities and prices means the Design Professional who signs the Change Order has personal knowledge that the quantities shown in the memorandum referred to under paragraph 7 above are correct, that he has personally satisfied himself that full credit has been extended for any work or materials deleted or omitted, and that he has conclusively established by such checking or inquire as may be necessary that the prices and allowances shown in the memorandum comparable with current costs for like services and materials.

Note to Design Professional: Please delete inapplicable language in parentheses and enter the dollar amount for this change. Insure that cost of the Work, percentage markup for profit, and the daily rate of general conditions costs is accurate and included in the amount of an additive change. If a deductive change, the amount is generally cost of the work only; however, consult with the owner in significant deductive Change Orders to determine if time or profit should be included in the deducted amount.

CHANGE ORDER FORMAT

(Force Account or Indeterminate Units)

CHANGE ORDER No. _______

Project Name: ____________________________ Project Number: __________________________

Owner

1. Submission of this Change Order for consideration was authorized by letter from the Owner, dated , 20__, Incumbrance Record No. .

2. The changes hereinafter described are applicable to the Contract for the construction of the above-referenced Project and amend the Contract Documents..

3. Description of Change:

4. This Change Order is deemed necessary and originated with the (Design Professional) (Owner) (Contractor) (Using Agency). (Indicate applicable entity.)

5. This Change Order is necessary to:

6. The Maximum Allowable Cost of the Change Order was estimated by:

NOTE TO DESIGN PROFESSIONAL:

Please prepare each Change Order in the form and wording given below, deleting inapplicable wording and adding such explanations as may be necessary. The wording in Paragraph 8 may not be changed or altered in any way by either the Design Professional or the Contractor. The wording in Paragraph 5 of the Final Cost Amendment may not be changed or altered in any way by either the Design Professional or the Contractor. Send four copies, signed by you and the Contractor, to the Owner. Do not forward a Change Order unless it is accompanied by a breakdown which has been checked by the Contract Compliance Specialist and Program Manager (if applicable).

Note to Design Professional:

Please leave the Change Order number blank. The Owner will assign a number.

Choose one:

a. Estimate in lump sum.

b. Unit prices stated in contract or subsequently agreed upon, and an estimated number of units.

c. Cost and percentage as described in general conditions.

Note to Design Professional:: No Change Order should be forwarded unless you have been furnished with a letter from the Owner authorizing same.

Note to Design Professional: Be sure to give a complete statement describing the changes in the work, including the specifications. If drawings are necessary, refer to them by date, etc., and state they are made a part of the Change Order. Copy of drawings should be attached to the Change Order.

Note to Design Professional: Give a complete description of conditions which necessitate the change.

7. A memorandum is attached showing the estimated cost breakdown of labor and materials by unit and quantities as prepared by the Contractor and checked by the Contract Compliance Specialist and Program Manager (if any).

8. The Maximum Allowed Cost for this Change Order is $ __________________________, and is established as Incumbrance Record No. _______________ . This Maximum Allowed Cost may be amended by the Owner in the event the actual costs are expected to exceed the Maximum Allowed Cost, provided that Contractor shall give written notice of such fact prior to incurring actual costs in excess of ninety percent of the Maximum Allowable Cost. In no event shall actual costs be incurred in excess of the Maximum Allowed Cost, as it may be amended.

APPROVED AND AGREED BY CONTRACTOR: RECOMMENDED FOR OWNER'S ACCEPTANCE

LEGAL GC Firm Name DESIGN PROFESSIONAL: LEGAL DP Firm Name

By: By:

(Print Name/Title) (Print Name/Title)

Date approved by Contractor: Date approved by Design Professional:

APPROVED AND AGREED BY USING AGENCY: APPROVED AND AGREED BY OWNER:

INSTITUTION NAME BOARD OF REGENTS OF THE UNIVERSITY

By: By:

(Print Name/Title) (Print Name/Title)

Date approved by Using Agency: Date approved by Owner:

FINAL COST AMENDMENT

TO

CHANGE ORDER NO. ___________

1. A memorandum is attached showing cost breakdown of labor and materials by unit and quantities as prepared by the Contractor and checked by the Contract Compliance Specialist and Program Manager (if any).

2. We have verified the quantity and quality of all materials shown on the memorandum. We have verified that all prices are reasonable and do not exceed current costs for like services or materials, and we have verified that the quality of the materials meets the requirements of the Contract Documents.

3. The contractor shall be allowed additional calendar days for completion. The Material Completion and Occupancy date is: __________________ .

4. The Contract Sum shall be (increased) (decreased) by $ _________________ on account of this change.

5. The payment and extension of time, if any, provided by this Change Order constitutes compensation in full to the Contractor and its Subcontractors, Suppliers, and Trade Contractors for all costs and markups, directly and indirectly attributable to the changes ordered herein, and for all delays or time related costs thereto and for any acceleration costs for performance of changes within the time stated and to be completed by the Material Completion and Occupancy Date and for any Claims related thereto against the Owner and the Design Professional, and design consultants.

APPROVED AND AGREED BY CONTRACTOR: RECOMMENDED FOR OWNER'S ACCEPTANCE

LEGAL GC Firm Name DESIGN PROFESSIONAL: LEGAL DP Firm Name

By: By:

(Print Name/Title) (Print Name/Title)

Date approved by Contractor: Date approved by Design Professional:

APPROVED AND AGREED BY USING AGENCY: APPROVED AND AGREED BY OWNER:

INSTITUTION NAME BOARD OF REGENTS OF THE UNIVERSITY

By: By:

(Print Name/Title) (Print Name/Title)

Date approved by Using Agency: Date approved by Owner:

Note to Design Professional: Please insert the number of additional Days allowed and the new Material Completion and Occupancy Date, or, if no additional time is allowed, insert “0” for Days and “No Change” for the date.

Note to Design Professional: Please observe the fact that verification of quantities and prices means the Design Professional who signs the Change Order has personal knowledge that the quantities shown in the memorandum referred to under paragraph 7 above are correct, that he has personally satisfied himself that full credit has been extended for any work or materials deleted or omitted, and that he has conclusively established by such checking or inquire as may be necessary that the prices and allowances shown in the memorandum comparable with current costs for like services and materials.

Note to Design Professional: Please delete inapplicable language in parentheses and enter the dollar amount for this change. Insure that cost of the Work, percentage markup for profit, and the daily rate of general conditions costs is accurate and included in the amount of an additive change. If a deductive change, the amount is generally cost of the work only; however, consult with the owner in significant deductive Change Orders to determine if time or profit should be included in the deducted amount.

APPLICATION FOR PAYMENT

APPLICATION FOR PAYMENT NO. PROJECT NO.

CERTIFICATE OF THE CONTRACTOR OR HIS DULY AUTHORIZED REPRESENTATIVE

To the best of my knowledge and belief, I certify that all items, units, quantities, and prices of work and material shown on this Application for Payment No. are correct; that all work has been performed and materials supplied in full accordance with the terms and conditions of the Contract Documents between

(Owner) and dated (Contractor) and all authorized changes thereto; and that the following is a true and correct statement of the contract account up to and including the last day of the period covered by this Application and that no part of the "amount due this Application" has been received.

(a) Total amount earned for work in place (original contract) $

(b) Total amount earned for work in place (Change Orders) $

(c) Value of materials stored at site $

(d) Total amount earned ( (a) plus (b) plus (c) ) $

(e) Amount retained (10%) $

(f) Total earned less retained percentage ( (d) minus (e) ) $

(g) Total previously approved $

(h) Amount due THIS ESTIMATE ( (f) minus (g) ) $

(i) Retainage payment to Subcontractors per Paragraph 4 .1.2.5 of the General Conditions. $

(j) AMOUNT DUE Contractor ( (h) minus (i) ) $

I further certify that all claims outstanding against the undersigned Contractor for labor, materials, and expendable equipment employed in the performance of said contract have been paid in full in accordance with the requirements of said contract, except such outstanding claims as are listed below or on the attached sheet, which statement contains all claims against the Contractor which are not yet paid, including all disputed claims and any claims to which the Contractor has or will assert any defense.

I further certify that all of the materials indicated on this Application for Payment as being stored on the Site, but not yet incorporated into the building, have been purchased, delivered, and are now stored on the Site for future incorporation into the building and until so incorporated the title to same is, upon payment of this statement, vested in the Owner. Furthermore, the undersigned Contractor assumes full responsibility for the existence, protection, and, if necessary, replacement of the above-mentioned materials until the completion of this contract.

Contractor By

Date Title

STATEMENT OF THE CONTRACT COMPLIANCE SPECIALIST

I have checked this Application for Payment and, to the best of my knowledge and belief, the statement of work performed and statement of materials stored on site by the Contractor are supported by my observations

Name Contract Compliance Specialist. Date:

CERTIFICATE OF THE DESIGN PROFESSIONAL

I certify that I have verified this Application for Payment and, to the best of my knowledge and belief, it is a true and cor rect statement of work performed and statement of materials stored on site by the Contractor and that the Contractor's certified statement of his account and the amount due him is correct and just. I further certify that all work has been performed and materials have been supplied in full accordance with the terms and conditions of the Contract Documents and authorized changes thereto.

Name Design Professional. Date:

SCHEDULE OF CHANGE ORDERS

In support of Application for Payment No.

Project No. Period Ending:

Contractor:

CHANGE ORDERS ADDITIONS DEDUCTIONS

Number (1)

Date (2)

Authorized Amount (3)

Amount this Period (4)

Completed Previous Periods

(5)

Authorized Deductions

(6)

WORK PERFORMED TO DATE

In support of Application for Payment Number:

For the period from: thru inclusive.

Project No.

Project Name and Address:

Contractor's Name and Address:

WORK INCLUDED IN ORIGINAL CONTRACT

DETAILED ESTIMATE WORK PERFORMED TO DATE

CSI Category and Description Item No. and Designation

(1)

Number & Kind of Units (2)

Unit Price

(3) Actual Cost

(4)

No. of Units

(5)

Amount Earned to

Date (6)

Value of Incomplete

Work (7)

Percent Complete

(8)

Division 00 - Procurement and Contracting Requirements: * a.

b.

c.

Division 1 - General Requirements * a.

b.

c.

Division 2 - Existing Conditions **

(i) Building a.

b.

c.

(ii) Infrastructure a.

b.

c.

Division 3 - Concrete * a.

b.

c.

Division 4 - Masonry **

(i) Building a.

b.

c.

(ii) Infrastructure a.

b.

c.

Division 5 - Metals * a.

b.

c.

Division 6 - Wood, Plastics, Composites * a.

b.

c.

Division 7 - Thermal and Moisture Protection *****

(i) Building a.

b.

c.

(ii) Infrastructure a.

b.

c.

Roof:

Division 8 - Openings * a.

b.

c.

Division 9 - Finishes * a.

b.

c.

Division 10 - Specialties *

Division 11 - Equipment ***

(i) Fixed or Built-in:

a.

b.

c.

(ii) Moveable:

a.

b.

c.

Division 12 - Furnishings ***

(i) Fixed or Built-in:

a.

b.

c.

(ii) Moveable:

a.

b.

c.

Division 13 - Special Construction * a.

b.

c.

Division 14 - Conveying Equipment * a.

b.

c.

Division 21 - Fire Suppression a.

b.

c.

Division 22 - Plumbing a.

b.

c.

Division 23 - HVAC ****

(i) Building

(ii) Infrastructure a.

b.

c.

Division 25 - Integrated Automation a.

b.

c.

Division 26 - Electrical **

(i) Building a.

b.

c.

(ii) Infrastructure a.

b.

c.

Division 27 - Communications a.

b.

c.

Division 28 - Electronic Safety and Security a.

b.

c.

Division 31 - Earthwork a.

b.

c.

Division 32 - Exterior Improvements a.

b.

c.

Division 33 - Utilities a.

Division 34 - Transportation b.

c.

Division 35 - Waterway and Marine Construction a.

b.

c.

Division 40 - Process Integration a.

b.

c.

Division 41 - Material Processing and Handling Equipment a.

b.

c.

Division 42 - Process Heating, Cooling, and Drying Equipment a.

b.

c.

Division 43 - Process Gas and Liquid Handling, Purification and Storage Equipment a.

b.

c.

Division 44 - Pollution and Waste Control Equipment a.

b.

c.

Division 45 - Industry-Specific Manufacturing Equipment

Division 46 - Water and Wastewater Equipment a.

b.

c.

Division 48 - Electrical Power Generation a.

b.

c.

Total Amount of Original Contract 0.00 0.00 0.00

+ or - total previously approved Change Order No's _____ included

+ or - Change Order No's _____ included approved during period covered by this est. _______

Total Net Adjusted Amount 0.00 0.00 0.00

NOTES: The following breakdowns must be accomplished in order to comply with Government Accounting requirements. Upon completion of the Project, the final Application for Payment must show all divisions and sections, and a Final Certification of Costs for Capital Asset Accounting completed and submitted with the Application for Final Payment.

* Report Items in each division, by CSI division and such other breakdown as is useful to the Contractor or Contract Compliance Specialist.

** These items must be broken down into 2 categories, (i) Building and (ii) Infrastructure reported by specification section.

Infrastructure for these purposes is defined as everything outside a line 5-feet from the building footprint.

*** These items must be broken down in to 2 categories; (i) fixed equipment & furnishings and (ii) Moveable equipment & furnishings and reported by specification section.

**** Division 23 - HVAC. This item must be broken down into 2 categories, (i) Building and (ii) Infrastructure, reported by specification section.

Chillers and HVAC units that serve the facility to be included as a part of the Building, even if they are outside the 5-foot limit.

Chillers and HVAC units that are outside the 5-foot limit and serve more than one facility, (i.e., equip. used in a central plant), to be included in Infrastructure.

***** Division 7 - Thermal & Moisture Protection of the Roof system should be reported as a separate line item. Generally, this includes components of Sections 7500 and 7600.

SUMMARY OF MATERIALS STORED

In support Application for Payment No.

Project No. Period Ending:

Contractor:

ITEM NO. NAME

(Contractor or Subcontractor)

TYPE OF

MATERIAL QUANTITY AMOUNT

(Dollars)

TOTALS

Prepared by for (Contractor)

Date , and certified by him to be a true and accurate statement.

Checked:

By:

Contract Compliance Specialist

Date:

SUBCONTRACTOR RETAINAGE RELEASE CERTIFICATE

(To be Originated by Subcontractor)

TO: Board of Regents of the University System of Georgia, Owner Institution Name, Using Agency

RE: Project Name and Number: Project Number and Description, Institution Name, City, State:

Certificate Regarding Subcontractor's Completed Work and Retainage Release

1. This is to certify that our work is one hundred percent complete for our subcontract number .

Our retainage is due in accordance with the contract documents. Our scope of work included the

. The total amount of retainage now due is $ .

2. The Subcontractor hereby certifies that all work required under the above contract has been performed in accordance with the terms thereof, that all materialmen, subcontractors, mechanics, and laborers have been paid and satisfied in full, and that there are no outstanding claims of any character (including disputed claims or any claims to which the subcontractor has or will assert any defense) arising out of the performance of the contract which have not been paid and satisfied in full except as listed hereinbelow, which exceptions apply only to the release in Paragraph 5, below:

[Enter: "None" or List or Make Reference & Attach Exhibit A.]

3. The Subcontractor further certifies that to the best of his knowledge and belief there are no unsatisfied claims for damages resulting from injury or death to any employees, subcontractors, or the public at large arising out of the performance of the contract, or any suits or claims for any other damage of any kind, nature, or description which might constitute a claim or lien upon the property of the Owner.

4. The Subcontractor has received final payment in full settlement of all claims against the Owner arising under or by virtue the contract, and acceptance of such payment is acknowledged as a release of the Owner from any and all claims arising under or by virtue of the contract. This release includes any claims set forth or excepted in Paragraph 2 above.

5. [Strike out if not applicable] The Subcontractor has received final payment in full settlement of all claims against the Contractor arising under or by virtue the contract, and acceptance of such payment is acknowledged as a release of the Contractor from any and all claims arising under or by virtue of the contract except as set forth in Paragraph 2 above.

6. Payments pursuant to this certificate shall in no way diminish, change, alter or affect the rights of the Owner under the contract documents.

SUBCONTRACTOR:

By: Date:

CONTRACTOR:

By: Date:

DESIGN PROFESSIONAL:

By: Date:

NOTICE: OWNER MUST RECEIVE A COPY WITH ALL ORIGINAL SIGNATURES.