CN-370000-GC130-T3CO1.pdf

Florida Department of Environmental Protection

TASK ASSIGNMENT CHANGE ORDER FORM

OOO-012 (Effective 10-13-2017) Page 1 of 2

Required Signatures: Adobe Signature

Task Assignment Number: Date: Change Order No.

Contractor Name:

Contractor Representative:

DEP Contract Manager:

Description of Change (Use additional sheets if necessary):

Change in Task Amount

Item Cost Reimbursement Fee Schedule Total Original Task Amount:

Task amount prior to this change order:

Net increase/decrease in task amount:

Task amount with all change orders:

Change in Task Time

Original task completion date:

Completion date prior to this change:

Net increase/decrease in task period:

Completion date with all change orders:

3 10/3/18 1

NorthStar Contracting Group

Kristy Trueblood

Robert Perlowski

1,889,017.72 1,889,017.72

1,889,017.72 1,889,017.72

54,642.00 54,642.00

1,943,659.72 1,943,659.72

6/30/19

6/30/19

N/A

6/30/19

Florida Department of Environmental Protection

TASK ASSIGNMENT CHANGE ORDER FORM

OOO-012 (Effective 10-13-2017) Page 2 of 2

Change in Funding Information

Budget Entity Project # Grant # Org Code Fund Special Category

Object Code

EO Amount

Total:

CONTRACTOR FLORIDA DEPARTMENT OF

ENVIRONMENTAL PROTECTION

Contract Manager Date Contract Manager Date

Program Administrator Date

APPROVED:

Budget Representative Date

Division Director Date

Deputy Secretary Date

Secretary Date cc: Procurement Section (MS93) Bureau of Finance & Accounting (MS78) - 2 copies

37450300 GC130 37450404555 212001 087889 131300 JG 54,642.00

10/4/18 10/4/18

54,642.00

10/4/2018

10/4/2018

Kristy Trueblood

Digitally signed by Kristy Trueblood Date: 2018.10.04 09:22:34 -04'00'

Robert Perlowski Digitally signed by Robert Perlowski Date: 2018.10.03 09:03:06 -04'00'

Austin Hofmeister Digitally signed by Austin Hofmeister Date: 2018.10.04 08:30:33 -04'00'

Derrick R.

Woodard II

Digitally signed by Derrick R.

Woodard II Date: 2018.10.04 08:56:21 -04'00'

Task Assignment Change Order Contract GC130, Task Assignment 3, Change Order 1

Description of Change:

This Change Order authorizes the addition of 400 Site Access Letters at $122.23 each for $48,892.00 in additional funding for Scope of Work 7A (Initial Site Access Letters), and the addition of 500 Certified Mail at $11.50 each for $5,750.00 in additional funding for Scope of Work 7E (Certified Mail Processing and Tracking).

Scope 7A (Initial Site Access Letters) + $48,892.00 Scope 7E (Certified Mail Processing and Tracking) + $5,750.00 Total change in funding = $54,642.00

This increase in funding is being made to reflect actual program workloads, and will result in a net increase to the original funding amount.

End of Change Order Description

Change in Task Amount