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City of South Bend <br />Department of Administration & Finance <br />Change Order Request Form <br />Multiple PO lines: <br />PO Number PO-0000617 <br />Line Number 1 <br />Original Dollar Amount $126,350.00 <br />New Dollar Amount <br />(For liquidation request, enter $0)$138,195.00 <br />Reason Code (if changed) <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)TIF River West: 324‐10‐102‐121‐442001‐‐PROJ00000046 <br />Project Code (if applicable)PROJ00000046 <br />Description of change (include <br />budget impact) <br />Addition of $11,845.00 to add the cost of potholing for existing utilities. This addition <br />will help determine the exact location of existing utilities to be avoided by new storm <br />sewer, and help avoid unexpected changes during construction. <br />Changing the line amount: <br />You can only change a line amount if it has NOT been invoiced against. <br />•If the line has NOT been invoiced – reduce the line amount to equal what it should be. <br />•If the line has been invoiced – cancel the delivery remainder and finalize the individual line, then add a new line for the <br />amount that should be remaining. <br />If you have changes to more than two lines on the same PO, fill out a separate section for each line affected by the change <br />order. <br />Amendment 1 - Change Order Request Form 1 of 5