Okaloosa County BOCC — February 4, 2014 — Purchasing Forms — reading text

CHANGE ORDER FORM Date: Contract No: Change Order No.: Owner: _ OKALOOSA COUNTY BOARD OF COUNTY COMMISSIONERS Contractor: Description of this summary change: CHANGE TO CONTRACT PRICE DESCRIPTION : : AMOUNT Original Contract Price: Net change by previously authorized Change Orders: Present Contract Price: This Change Order will (add/deduct): New Contract Price: CHANGE TO CONTRACT TIME DESCRIPTION DATE or NUMBER OF DAYS Original Contract Date: Original Substantial Completion Date: Net change by previously authorized Change Orders: This Change Order will (add/deduct): New Contract Date: New Substantial Completion Date: APPROVALS REQUESTED BY: DATE: PROJECT ENGINEER: DATE: CONTRACTOR: DATE: OWNER: DATE: This Change Order is an amendment to the Contract / Agreement between Contractor and the Owner, and all other contract provisions shail remain in full force and effect unless specifically amended in writing, signed by both parties. 46 CONTRACT CONTROL NUMBER C83-0013-RM c 83 0013 RM Contract FY Consecutively Department Assigned Control # LEASE CONTROL NUMBER L90-0114-AP L 90 0114 AP Lease FY Consecutively Department Assigned Control # CONTRACT, LEASE, AGREEMENT CONTROL FORM Date: Contract/Lease Control #: Bid #: Contract/Lease Type: Award To/Lessee: Lessor: Effective Date: Term: Description of Contract/Lease: Department: Department Monitor: Monitor's Telephone #: Monitor's FAX # or E-mail: Date Closed: cc: Finance Department Contracts & Grants Office 48 CONTRACT & LEASE INTERNAL COORDINATION SHEET Contract/Lease Number: Tracking Number: ____ Contractor/Lessee Name: Grant Funded: YES___. NO___ Purpose: Date/Term: 1. (.] GREATER THAN $50,000 Amount: 2. [) GREATER THAN $25,000 Department: 3. [1] $25,000 OR LESS Dept. Monitor Name: Document has been reviewed and includes any attachments or exhibits. Purchasing Review Procurement requirements are met: Date: Purchasing Director or designee Risk Management Review Approved as written: Date: Risk Manager or designee County Afforney Review Approved as written: Date: County Attorney Following Okaloosa County approval: Contract & Grant Document has been received: Date: Contracts & Grants Manager 49 EMERGENCY Contract / Lease Form Contractor/Lessee Name: Purpose: Date/Term: Amount: Department: Justification must be given as to why the above referenced contract/lease is considered an emergency and therefore NOT in accordance with the approved Okaloosa County’s contract/lease policy and procedures. Approved: Department Director Date County Administrator Date Purchasing Director Date 50 CONTRACT CLOSE-OUT CHECKLIST (To Be Prepared by the Purchasing Services Coordinator) DATE: TO: Contracts & Grants Manager, Finance Department Contracts & Grants Office SUBJECT: Contract No. MANAGING DEPARTMENT: CONTRACTOR'S NAME: PROJECT TITLE: The attached has met the final payment contract requirement in subject contract. Yes No 1. Final Invoice O ma 2. Completed Contract/Lease Payment Approval Form oO O 3. Close-Out Documents Yes No N/A a. Signed Release of Lien Cl C] im b. Proof of Completion Advertisement [ C] im c. Certificate of Insurance im [] C] d. Consent of Surety to Final Payment Cl L] [] e. Proof of Performance/Payment Bond O Oo C Continuation 12 Months Following Final Payment Yes No 4. Agenda Request oO i 5. Remarks Purchasing Services Coordinator DATE 51 CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT DEPARTMENT E & — —— COMPLETED BY DEPARTMENT DATE: VENDOR NAME: VENDOR #: CONTRACT/LEASE #: VENDOR TASK COUNTY/FEMA BUDGET ACCOUNT # AMOUNT $ INVOICE# ORDER # PROJECT # DEPARTMENT # (if Applicable) (ff Applicable) TOTAL APPROVED FOR PROGRESS PAYMENT (please sign, as applicable and date) CONTRACTOR’S ENGINEER/ARCHITECT/PROJECT MANAGER: DATE: COUNTY SUPERVISOR/PROJECT MANAGER: DATE: DEPARTMENT DIRECTOR: DATE: CONTRACTS & GRANTS MANAGER: DATE: COUNTY ADMINISTRATOR: DATE: (Payments> $25,000.) E J] FINAL PAYMENT FINAL PAYMENT YES. NO (If “Yes”, forward to Purchasing Services Coordinator for Close-Out) DATE: PURCHASING DIRECTOR (Per Initial Agreement) DATE: CONTRACTS & GRANTS MANAGER (All Contracts) DATE: COUNTY ADMINISTRATOR APPROVAL (Per Initial Agreement) DATE: BOARD APPROVAL {Per Initial Agreement) — E j COMPLETED BY FINANCE — ACCOUNTS PAYABLE ONLY FISCAL YEAR: DATE RECEIVED: REVIEWED BY: 52 CONTRACT/LEASE PAYMENT APPROVAL FORM INSTRUCTIONS Contract/Lease (Agreement) Payment Approval Form must be used for any lease or contract payment Department Responsibilities: 1. 8. Initiates the Payment Approval Form completion process by completing Department section and then forwarding to the Contracts & Grants Manager for Progress Payments only. For final payments, see section 7 below. identifies the Vendor/Contractor Name and Vendor Number. Lists the contract/lease number. Attach the Vendor/Contractor invoice along with all supporting documentation for a pre and post audit. This must be an invoice and not a statement. [f pursuant to a task order contract, invoice should reference task order number, authorized amount, prior paid amount, current amount due and task order balance remaining. Identify appropriate budget, account and amount information for payment. Obtain approval of all signatories approving this payment, as identified below. on Contractor's Engineer/Architect/Project Manager: Signs the form verifying that the work on the invoice has been completed in accordance with the terms and conditions of the agreement. b. County Supervisor/Project Manager: A County-designated employee or consultant signs the form verifying that the work on the invoice has been completed in accordance with the terms and conditions of the agreement and that the payment request on the invoice is proper and due. c. Department Director: Signs the form verifying that the work on the invoice has been completed in accordance with the terms and conditions of the agreement, including verification of contract rates, and that the funds are appropriately budgeted and available. Signs and approves all payments including final payment. Final payments shall be forwarded to the Purchasing Services Coordinator for final payment authorization and close-out in accordance with the policies and procedures herein. Finance Department Contracts & Grants Office Responsibilities: 1. Finance Department Contracts & Grants Office signs the form verifying that an original agreement is on file in the Clerk's Office and that the accounting codes are appropriate. Finance Department Contracts & Grants Office shall forward all fully executed forms for progress payments up to and including $25,000 to the Accounts Payable Department who verifies the form(s) have all the required approvals and signatures prior to authorizing payment. Finance Department Contracts & Grants Office forwards to the County Administrator to sign and approve all progress payments in excess of $25,000. County Administrator also signs final payments for contracts initially authorized by him/her. Fully executed forms are forwarded to 53 Finance Accounts Payable Department, which shall verify that the form includes all the required approvals and signatures before authorizing payment. Finance Department Contracts & Grants Office shall forward the fully executed Final Payment forms from the Purchasing Director who signs and approves only the final payments on initial contracts authorized by him/her to Finance Accounts Payable Department for review and payment. Finance Department Contracts & Grants Office forwards all other final payments for contracts initialy authorized by the Board BCC Records in support of the agenda for Board approval. Fully executed forms are forwarded to Finance Accounts Payable Department for review and payment. 54 NOTICE OF COMMENCEMENT STATE OF FLORIDA COUNTY OF OKALOOSA The undersigned hereby informs all concerned that improvements will be made to certain real property and, in accordance with Section 713.13 of the Florida Statutes: the following information is stated in this NOTICE OF COMMENCEMENT: LEGAL DESCRIPTION OF PROPERTY TO BE IMPROVED (if lengthy, attach copy) Street Address (if any) General Description of improvements Owner Okaloosa County Board of County Commissioners Owner's Interest 100% Address__302 N. Wilson St. Crestview, Florida 32536 Fee Simple Titie Holder (If other than Owner}__NA Address__NA GENERAL CONTRACTOR Name. Address. Surety Bond__NA Address__NA Amount of Bond $_ NA NAME AND ADDRESS OF FINANCIAL INSTITUTION MAKING A LOAN FOR THE CONSTRUCTION OF THE ABOVE IMPROVEMENTS Name__NA Address_ NA PERSONS WITHIN THE STATE OF FLORIDA DESIGNATED BY OWNER UPON WHOM NOTICES OR OTHER DOCUMENTS MAY BE SERVED AS PROVIDED BY SECTION 713.13(1)(a)7, FLORIDA STATUTES Name__ Finance Department Contracts & Grants Office Address_Clerk of Courts, 1804 Lewis Tumer Blyd., Ft. Walton Beach FL_32548 IN ADDITION TO HIMSELF, OWNER DESIGNATES THE FOLLOWING PERSON TO RECEIVE A COPY OF THE LIENOR'S NOTICE AS PROVIDED IN SECTION 713.13(1)(b), FLORIDA STATUTES (FILL IN AT OWNER'S OPTION). Name__ Purchasing Services Coordinator Address _602-C North Pear Sireet, Crestview, FL 32536 EXPIRATION DATE OF NOTICE OF COMMENCEMENT (THE EXPIRATION DATE IS 1 YEAR FROM THE DATE OF RECORDING UNLESS A DIFFERENT DATE IS SPECIFIED). THIS SPACE FOR RECORDER'S USE ONLY {attest to the coreciness of the information above. Authorized Department Signature The foregoing instrument was acknowledged before me this day of CO, by . who is personally known to me or who has produced as identification and who did/did not take an oath. NOTARY PUBLIC MY COMMISSION EXPIRES 55 TASK ORDER APPROVAL FORM CONTRACT #: TASK ORDER #: TASK ORDER AMOUNT: $ OFFERED BY CONSULTANT: FIRM'S NAME REPRESENTATIVE’S PRINTED NAME SIGNATURE TITLE DATE RECOMMENDED FOR APPROVAL APPROVED BY OKALOOSA COUNTY (Department Director) (Per Purchasing Manual) « $25,000 or less approved by Purchasing Director ¢ Between $25,001 and $50,000 approved by Purchasing Director and County Administrator « In excess of $50,000 approved by the Board. SIGNATURE PURCHASING DIRECTOR TITLE DATE DATE COUNTY ADMINISTRATOR (if applicable) CHAIRMAN (if applicable} CONTRACT/LEASE RENEWAL FORM Date: Company Name Attn: Address City, State, Zip RE: Dear The Okaloosa County agrees to renew the subject contract/lease, # for an additional term. The contract renewal period will be _ to . The annual budgeted amount for this contract is $ If you are in agreement, please sign below and return this form along with a current Certificate of Insurance listing Okaloosa County as co-insured (if applicable). COUNTY REPRESENTATIVES AUTHORIZED COMPANY REPRESENTATIVE Dept. Director Contractor: Signature: Approved By: Approved By: {as prescribed below on item 1) Title: Title: Date: Date: County Department instructions: 1) Obtain signatures from Department Director, authorized Company Representative and then Purchasing Director <$25K and less, County Administrator <$50K and less or Board >SS5OK, as necessary. If Board approval is required, the Chairman and County Administrator's signatures are required. Make sure the company provides a current Certificate of Insurance. (if applicable). 2) Keep a copy of this form for your records. 3) Send original to Purchasing Services Coordinator. If you have any questions please contact the Purchasing Director at 850-689-5960, Fax: 850-689-5998, 57 OKALOOSA COUNTY BOARD OF COUNTY COMMISSIONERS COUNTY ISSUED WIRELESS COMMUNICATION DEVICE USAGE AGREEMENT CERTIFICATION COUNTY OFFICIAL/EMPLOYEE CERTIFICATION ! hereby certify by my signature that | have read and understand the County policy for Wireless Communication Device; that | understand the requirements contained therein; and that | agree to comply with the requirements of the policy as now written or amended in the