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City of South Bend <br />Department of Administration & Finance <br />Change Order Request Form <br />Multiple PO lines: <br />Project POs: <br />PO Number PO-001766 (V-00001372 Frost Engineering and Consulting) <br />Line Number Add Line Item 2 "Amendment 1", Amount $3,167.79 <br />Original Dollar Amount $28,000.00 <br />New Dollar Amount <br />(For liquidation request, enter $0)$31,167.79 <br />Reason Code (if changed)N/A <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)201-11-201-201-431000 <br />Project Code (if applicable)PROJ00000358 <br />Description of change (include <br />budget impact) <br />PROJ00000358 Potawatomi Pool Assessment <br />Amendment No. 1 includes increased costs for additional services requested by <br />Venues, Parks and Arts for Frost Engineering and its subconsultants to develop a <br />presentation, attend and present assessment findings to the Park Board at its <br />meeting on November 21, 2022. This work was not included in the original scope of <br />work. Compensation requested by Frost Engineering for this additional service is <br />$3,167.79. An Amendment will be issued to the Board of Public Works to amend the <br />existing Professional Services Agreement on 12/13/2022. <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 />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 />For change orders on project-related POs, this form must be approved by the Project Accounting Team as described in <br />Supplement 508. <br />Change Order Request Form PO-0017966 2022.12.05 1 of 4