CN-370000-GC714-T43CO1.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:

43 10/23/17 1

York Risk Services Group, Inc.-Florida

Brian King

Robert Perlowski

209,428.26 209,428.26

209,428.26 209,428.26

0.00 0.00

209,428.26 209,428.26

10/31/17

10/31/17

N/A

10/31/17

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 GC714 37450404555 212001 087889 131545 JG 0.00

0.00

Brian King Digitally signed by Brian King DN: cn=Brian King, o=York RSG, ou=202, email=brian.king@yorkrsg.com, c=US Date: 2017.10.27 08:34:01 -04'00'

Robert Perlowski Digitally signed by Robert Perlowski Date: 2017.10.24 14:53:20 -04'00'

Austin Hofmeister Digitally signed by Austin Hofmeister Date: 2017.10.26 11:02:49 -04'00'

Jennifer Vickers Digitally signed by Jennifer Vickers Date: 2017.10.26 15:48:34 -04'00'

Florida Department of

Environmental Protection

Bob Martinez Center 2600 Blair Stone Road

Tallahassee, Florida 32399-2400

Rick Scott Governor

Carlos Lopez-Cantera

Lt. Governor

Noah Valenstein Secretary

Task Assignment Change Order Contract GC714 Task Assignment 43 Change Order 1

Description of Change:

This Change Order authorizes the transfer of $3,024.50 in funding from Scope of Work 9a (DOH Site Priority Scoring and Tracking) and $1,250.00 from Scope of Work 9c (DOH Well Survey Request and Tracking) to:

Scope 3d (LSA Follow-up Letters) $750.00 Scope 3e (LSA Self Addressed Stamped envelopes) $150.00 Scope 4b (SAA Follow-up Letters) $750.00 Scope 4c (SAA Self Addressed Stamped envelopes) $130.00 Scope 4e ((SAA Certified Letters) $675.00 Scope 8 (Utility Payment Processing) $1,819.50

This transfer in funding is being made to reflect actual workloads, and will not result in any net increase or decrease to the original funding amount.

End of Change Order Description

Change in Task Amount