CN-370000-HW556-BF563A-1.pdf

DEP CONTRACT NO.

Task Assignment #: Change Order No.:

Contractor Name:

Contractor Representative:

DEP Contract Manager: Phone #:

Site Name:

Site ID / Facility ID::

Description of Change [use additional pages if necessary]:

The Deliverable and Invoice Schedule is attached.

Final Deliverable:

TASK ASSIGNMENT TYPE AND NOT TO EXCEED AMOUNTS:

Cost Reimbursement Fixed Fee

Original Task Amount

Task Amount Prior to this Change Order Net Increase/decrease in task amount Task amount with all change orders

$0.00 $0.00 $0.00 $0.00

Original Task Completion Date:

Completion Date Prior to this Change:

Net Increase/Decrease in Task Period:

Completion Date with all Change Orders:

DEP Task Manager:

DEP Contract Manager:

Contractual Authority:

Contractor Representative:

CC: Procurement Section (MS 93) Section Representative ________

FIXED PRICE

TASK ASSIGNMENT NOTIFICATION CHANGE ORDER FORM

ITEM

$0.00

$0.00

DEP will review the deliverables to verify that they meet the specifications of this contract and task description. DEP’s Contract Manager shall notify the Contractor of any deficiencies in the deliverable(s) and shall give the Contractor reasonable opportunity to correct noted deficiencies and provide a revised deliverable(s).

Final Deliverable Due Date:

$0.00

$0.00

CHANGE IN TASK TIME

FEE SCHEDULE

COST PLUS FIXED FEE

TOTAL

WCP TAFORM 01_18

Task Assignment Notification/Change Order Deliverables and Invoice Schedule Attachment

BWC TAFORM 2/03

Contract Number:

Task Assignment #:

Deliverables:

Deliverable Deliverable Due Date

Invoice Schedule:

Requirements for Invoice Submittal Amount to be Invoiced

TOTAL COST