STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
375-030-1A
PROFESSIONAL SERVICES
REQUEST FOR SUPPLEMENTAL AMENDMENT
Contract No.
PROCUREMENT
04/99
Proposed Amendment Number
Consultant
Project Description
Funds Have Been Programmed in FDOT FM no.(s)
Federal Funding:
None
Oversight
Non-Oversight
Other
FAP No.
Original Agreement Fee
Previous Supplements
(No. of Previous Supplementals
)
Current Total Fee
Proposed Supplemental Fee
Proposed Total Fee
Contract No.
Proposed Fee Breakdown Attached
Scope of Services for Supplemental Services Attached
End of Services Date:
Current
Proposed
Justification for Supplemental Services:
Click on this form field and type explaination
The undersigned requestor affirms that the proposed supplemental services are not included within the original
scope of services, are not a result of errors and omissions of the Consultant, and fall within the originally advertised
project intent and limits. It is further affirmed that the undersigned requestor has performed an independent
assessment of the staff hours and quantities for the proposed supplemental services and has found them to be fair,
competitive and reasonable. (These certifications do not apply to task assignment contract.)
Requested by
(Name)
(Date)
(Signature)
Managerial Approval
(Name)
(Date)
(Signature)
For FHWA Oversight Projects:
FHWA approved received from
(Name of Area Engineer)
(Date)