Laserfiche WebLink
City of South Bend <br />Department of Administration & Finance <br />Change Order Request Form <br />Multiple PO lines: <br />Project POs: <br />PO Number 18048 <br />Line Number 5 <br />Original Dollar Amount $1,161,746.00 <br />New Dollar Amount <br />(For liquidation request, enter $0)$1,228,927.00 $67,181.00 <br />Reason Code (if changed) <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)408-06-602-503-436008 <br />Project Code (if applicable)330 <br />Description of change (include <br />budget impact)Change Order #1 increase scope on project per Scott K <br />APPROVED BY PROJECT <br />ACCOUNTING TEAM (if applicable)Ron O'Connor 09/21/2022 <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) <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 />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 <br />change order. <br />For change orders on project-related POs, this form must be approved by the Project Accounting Team as described in <br />Supplement 508. <br />PO-18048 Reith Riley Construction PROJ-330 Increase Line 5 - ADD 67181.00 09-21-2022 per Scott K 1 of 3