DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD

AC&I FINAL DATA FORM CIVIL ENGINEERING PROJECT

Date: Prepared By (Name & Place):

Project Title: Fiscal Year of Project:

Unit Name: OPFAC Number:

SFRL Number: PPR Number:

PP Number: AC&I Project Number:

Brief Project Description:

Estimated IFB Stage Construction Time (Days): Contract Award Amount ($):

Construction Start Date: Number of Change Orders:

Construction Complete Date: Net Cost of Change Orders ($):

Actual Construction Time (Days): Final Project Cost ($):

CATEGORY CODE GROSS SQUARE FEET NET SQUARE FEET

Other Comments (i.e. Excessive Construction Time, Contractor Defaulted, Contractor Claims, etc.):

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Date: Prepared By (Name & Place):

Project Title: Fiscal Year of Project:

Unit Name: OPFAC Number:

SFRL Number: PPR Number:

PP Number: AC&I Project Number:

List the Cost and Scope of All Major Contract Change Orders

Indicate if the reason for the change order is attributed to:A - Design Omission;B - Value Engineering Incentive;C - CQC; orD - Change in Operational of Functional Requirements.

Indicate in which cost item the change order should be accounted:1 - Demolition;2 - Sitework;3 - Exterior Utilities;4 - Waterfront/Marine Construction;5 - Building Construction

6 - Outfitting/Furnishings/Equipment;7 - Electronics; or8 - Other.

Attach additional sheets if necessary.

INSTRUCTIONS• •

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CHANGE ORDER NUMBER REASON SCOPECOST

ITEM COST