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CONTRACT MODIFICATION FORM <br /> STATE OF HAWAII <br /> DEPARTMENT OF HEALTH <br /> Date January 27,2012 <br /> ADM.SERV. OFFICE LOG NO. 10-189 MODIFICATION ORDER NO. 3 <br /> Contractor/Provider County of Hawaii <br /> Contract Title Underage Drinking Prevention Plan Under Hawaii's Strategic Prevention <br /> Framework-State Incentive Grant Phase li Funding RFP for the County of Hawaii <br /> A. MODIFICATIONS <br /> The following modifications are to be performed in accordance with all contract <br /> stipulations (specifications, delivery point, rate of delivery, period of performance, price, <br /> quantity, or other provisions by mutual action of the parties to the contract). <br /> See attached for Contract Modification(s). <br /> B. CONTRACTOR/PROVIDER's QUOTATION <br /> The modifications described in A, above,will be performed at a contract price <br /> E21 increase ❑decrease of$1,008,428.21. The Contractor/Provider will not undertake <br /> to perform the changes in A, above, until this modification order has been approved and <br /> issued, .. _ <br /> Contractor/Pr¢vider's Signature <br /> C. STATEMENT OF CONTRACT FUNDS <br /> Original Contract Price $ .103.140.28 <br /> Previous Adjusted Contract Price $ 1,226,841.12 <br /> Amount of this Change: Plus © Minus ❑ $ 1,008,428.21 <br /> New Adjusted Contract Price $ 2,235,269.33 <br /> D. VALIDATION OF CONTRACT MODIFICATION <br /> Director of Health Date <br /> ASO-MOD FORM <br /> (rev.4/30/04) <br />