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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 14130 <br />Line Number 3 <br />Original Dollar Amount $0.00 <br />New Dollar Amount <br />(For liquidation request, enter $0)$25,410.00 <br />Reason Code (if changed) <br />Financial Dimensions (fund-dept- <br />division-subdivision-main account)101-04-040-040-443001-ARP019 <br />Project Code (if applicable)PROJ-297 <br />Description of change (include <br />budget impact)MAU connect to existing hot water loop <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 />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 />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 one line 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 - MPAC GESC PO 14130 1 of 3