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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 5039 <br />Line Number 3 (new) <br />Original Dollar Amount $448,595.00 <br />New Dollar Amount <br />(For liquidation request, enter $0)$478,985.00 <br />Reason Code (if changed)n/a <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)430-10-102-121-443001 <br />Project Code (if applicable)57 <br />Description of change (include <br />budget impact)Add Line 3 for Project Change Order #2: $30,390.00 <br />APPROVED BY PROJECT <br />ACCOUNTING TEAM (if applicable)Amanda Pietsch - use project category 443001 <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 />2021 April 15 PO-5039 - PO Change Order Request Form Proj-57 (1)1 of 8