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City of South Bend <br />Department of Administration & Finance <br />Change Order Request Form <br />New Dollar Amount <br />(For liquidation request, enter $0)$245,458.00 <br />Reason Code (if changed) <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)PROJ00000087 and project category 429-443001 <br />Project Code (if applicable)PROJ00000087 and project category 429-443001 <br />Description of change (include <br />budget impact)Change Order #3: Earth Retention System for Cascades Phase II <br />APPROVED BY PROJECT <br />ACCOUNTING TEAM (if applicable)(PAT member's name and date to be completed by PAT member) <br />PO Number PO 6342 <br />Line Number 9 <br />Original Dollar Amount $0.00 <br />New Dollar Amount <br />(For liquidation request, enter $0)$20,817.00 <br />Reason Code (if changed) <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)201-11-206-273-444000--PROJ00000079 <br />Project Code (if applicable) <br />Description of change (include <br />budget impact) <br />Change Order #4. Pavillion - Hardware upgrade, credit on FRP, and additional stain <br />and finish on all Accoya Wood. <br />APPROVED BY PROJECT <br />ACCOUNTING TEAM (if applicable)Amy Shirk 10/15/2021 <br />PO Number <br />Line Number <br />Original Dollar Amount <br />New Dollar Amount <br />(For liquidation request, enter $0) <br />Reason Code (if changed) <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account) <br />Project Code (if applicable) <br />Description of change (include <br />budget impact) <br />APPROVED BY PROJECT <br />ACCOUNTING TEAM (if applicable)(PAT member's name and date to be completed by PAT member) <br />PO Number <br />Line Number <br />Original Dollar Amount <br />New Dollar Amount <br />(For liquidation request, enter $0) <br />Reason Code (if changed) <br />CO#4 PO-0006342 Ziolkowski CO#4 2 of 3