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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-0016353 <br />Line Number 1 <br />Original Dollar Amount $2,885,243.00 <br />New Dollar Amount <br />(For liquidation request, enter $0)$2,899,756.00 <br />Reason Code (if changed)na <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)622-06-604-620-42005 <br />Project Code (if applicable)PROJ-56 <br />Description of change (include <br />budget impact) <br />Revised the sand effective size, requiring a change in vendor and an increase in <br />price. Also extending the completion date. <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 />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 />PO-0016353 North WTP Change Order 1 1 of 5