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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-0005021 -- Bowen Engineering <br />Line Number Add Line 5 - Increase Total Amount by $10,320.00 "Change Order No. 4" <br />Original Dollar Amount $4,475,585.23 <br />New Dollar Amount <br />(For liquidation request, enter $0)4,485,905,23 (Includes Change Order No. 4, Increase of $10,320.00) <br />Reason Code (if changed)N/A <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)641-06-605-515-439001 <br />Project Code (if applicable)N/A <br />Description of change (include <br />budget impact) <br />Change Order No. 4 reflects additional scope of work required to bulkhead leaking <br />Aeration Gates at Aeration Tanks 1-4 during construction to keep water off of the <br />contractor during new gate installations. This change order also included Owner <br />directed electrical work to add a receptacle for the disinfection processes for a <br />reserve sulfur dioxide mixer. <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 CHANGE FORM for PO-0005021 2022.11.14 1 of 5