Contract Approval for Real Estate by kls68623

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									                                                                             OFFICE OF REAL ESTATE & FACILITIES


                                                                                                                                                                                                A
                                                                 Mississippi Board of Trustees of State Institutions of Higher learning

                                                                                                                                                                               FORM
                                       REQUEST FOR PROJECT-RELATED                                                STAFF APPROVALS
To: Assistant Commissioner of Real Estate & Facilities
                                          Institution Name:                                                                                                               IHL Staff Use Only

                                              Project Number:
                                                Project Name:
                                     Design Professional:
                                      General Contractor:
Total Project Budget: (Estimated breakdown and source of funds $                                                                                     -
                                              must be provided below)

I. Actions Requiring System Office Staff Approval/Submission
    Check all that apply:
Approval        Estimate                                                                              Approval
Requested       Attached                                                                              Requested
      √            √        Please attach estimates where applicable                                       √
                            Schematic Design                                                                         Advertise/Receive Bids
                            Design Development                                                                       Award of Project :        Certified Bid Tabulation Attached (required)
                            Contract Documents                                                                       Waiver of Design Development Submittal
                            Change Order (requires submission of Change Order Summary - Form C.)

II. Actions Requiring System Office Staff Notification
 Submittal

      √
               Initiation of Project (for projects $1M and less utilizing any state bond funds or Ayer's funds. List project budget information below)
               Change in Total Project Budget (Projects $1M and less)
III. Source of Funds                                      Amount                          Bond Bill Number / Explanations                                     IHL Staff Use Only
State Bond Funds                                  $                      -
                    (List amount and Bond Bill
State Bond Funds                                  $                      -
                    (List amount and Bond Bill
State Bond Funds                                  $                      -
                    (List amount and Bond Bill

           Self-Generated Funds (Explain) $                              -
                                EBC Bonds $                              -
                               Other (Explain) $                         -
             TOTAL PROJECT BUDGET: $                                     -
IV. Additional Information (if needed)




V. Project Budget: Estimated Breakdown
$                                         -      Origional Contract Amount
$                                         -      Design Professional Fees
$                                         -      Miscellaneous Project Costs
$                                         -      Furniture & Equipment (if applicable)
$                                         -      Total Change Orders (including any Change Order requested herein)
$                                         -      Contingency
$                                         -      TOTAL PROJECT BUDGET (Increase in total for Projects over $1M requires Board of Trustees approval, Form B)

VI. Certification and Approvals
      √
               I certify that the four conditions approved at project initiation (Scope, Budget, Funding Source, Design Professional) have NOT changed.
          Facilities/Physical Plant Director's Signature:
                                                                                                                                                     Date Signed:
                                                        (required)

           Chief Financial Officer's Signature: (required)                                                                                           Date Signed:

           Institution's Executive Officer's Signature: (if                                                                                          Date Signed:
                                    applicable per the institution)

Assistant Commissioner for Real Estate & Facilities
                                                                                                                                                     Date Signed:
                              Approval Signature:


      September 2010                                                                                                                                                Project-Related Staff Approval

								
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