Change Order No 2 - Brick Pavement Spot Repair Proj No. 121-019 - Acorn Landscaping LLC

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City of South Bend Department of Administration & Finance Change Order Request Form Multiple PO lines: Project POs: PO Number PO-0010848 Line Number 1 Original Dollar Amount $134,694.00 New Dollar Amount (For liquidation request, enter $0)$161,321.00 Reason Code (if changed) Financial Dimensions (fund-dept- division-subdivision-main account)455-06-600-506-442001 Project Code (if applicable)PROJ00000283 Description of change (include budget impact) Increase of $26,627.00 (+19.77%) to cover necessary additional brick pavement spot repairs within the predetermined project limits. APPROVED BY PROJECT ACCOUNTING TEAM (if applicable)Ron O'Connor 10-14-2021 PO Number Line Number Original Dollar Amount New Dollar Amount (For liquidation request, enter $0) Reason Code (if changed) Financial Dimensions (fund-dept- division-subdivision-main account) Project Code (if applicable) Description of change (include budget impact) APPROVED BY PROJECT ACCOUNTING TEAM (if applicable)(PAT member's name and date to be completed by PAT member) PO Number Line Number Original Dollar Amount Changing the line amount: You can only change a line amount if it has NOT been invoiced against. • If the line has NOT been invoiced – reduce the line amount to equal what it should be. • If the line has been invoiced – cancel the delivery remainder and finalize the individual line, then add a new line for the amount that should be remaining. If you have changes to more than one line on the same PO, fill out a separate section for each line affected by the change order. For change orders on project-related POs, this form must be approved by the Project Accounting Team as described in Supplement 508. PO-10848 PO Change Order Request Form increase 26627.00 Leslie - ro 1 of 3