Fort Walton Beach Resolution — 2024-18 Authorizing $48,400 to FDOT for Eglin Pkwy Improvements — reading text

Re: DOT —K 11- 78, Financial project # In order for FDOT to receive credit for the funds due to the Department, the reference line must contain " FDOT" and an abbreviated purpose, financial project number or LFA account number. Once the wire transfer is complete, please contact Charmaine Small at 850- 414- 4885 with the following information: Financial Project Number, Dollar amount of transfer, Name of Participant It is critical that the above information be provided to the LFA accountants to properly process the deposit. SUBSTITUTE FORM W9: The Department of Financial Services now requires all entities who receive payments from the State of Florida to have a Substitute Form W-9 on file. All cash disbursements ( return of cash collateral or earned income) will be subject to this requirement. The Substitute Form W-9 can be completed online through the State of Florida Vendor Portal Website ( haps:// flvendor.inyfloridacfo. com/). Docusign Envelope ID: C46140C1- 66A5- 406E- 851F- 8F4ED224FEB8 STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 350- 020- 03 AGREEMENT SUMMARY SHEET COMPTROLLER 9/ 18 Attach this completed form to the agreement and forward to the LFA Section in the OOC, General Accounting Office, M. S. 42B. If you have have any questions, please call 850- 414-4867 or 850- 414- 4889. 1 Participants Name: CITY OF FORT WALTON BEACH Participants Address: 107 Miracle Strip Parkway City, State, Zip: Ft. Walton Beach, FL 32548 Contact: Daniel Payne Phone Number: 850- 833- 9613 E -Mail Address: dpayne@fwb. org Fax Number: Federal Employer ID # and address sequence: F596000323005 FEID# has a verified W-9 registered with the Department of Financial Services Yes No In Process 2. Refund Address: same as above DS 3. District Contact Person: — Kathy Ozmore Phone Number: 850- 466- 4122 District Number: Fax Number: l Chipley ZU 4. Agreement Date: 1i: Z1 AM EST 5. Date Form Modified: 6. Agreement Amount: 48, 400. 00 7. Escrow Deposit Due Date: 1- 30- 2025 Amount Due: $ 48, 400. 00 Additional Deposit Due Date: Amount Due: $ Additional Deposit Due Date: Amount Due: $ 8. County Name: OKALOOSA 9. FDOT County Number: 57 10. If fund type is LFR/ LFRF ( Yes No), what is the anticipated start date of the payback: Is payback to be made in: Scheduled Payments Quarterly Lump Sum 11. Participant is responsible for (check one): 0100% Other Percentage ( %) Bid Items ® Lump Sum If participant is responsible for bid items, please complete the attached spreadsheet. 12. Description of work: 8 manholes & 8 valve boxes to be adjusted by the Highway Contractor 13. Financial Project # 15. Work 16. Federal Part or 14. Amount Program Fund Non -Federal Part. 17. Contract # 18. % to Bill Including 6x Phases Code 450813- 1- 52- 04 48, 400. 00 LF 0 19. Has WP been updated to reflect the changes on this form? ® Yes No 20. Comments This is a Lump Sum Agreement and includes an additional 10% in the cost.