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City of South Bend <br />Department of Administration & Finance <br />Change Order Request Form <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 />Multiple PO lines: <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 />Project POs: <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 Number <br />13835 <br />Line Number <br />Add line 4 <br />Original Dollar Amount <br />$0.00 <br />New Dollar Amount <br />$470,950.00 <br />For liquidation request, enter $0 <br />Reason Code if changed) <br />SV-ES - no change <br />Financial Dimensions (fund-dept- <br />416-11-220-292-443001--PROJ00000294 <br />division -subdivision -main account <br />Project Code if applicable) <br />PROJ00000294 <br />Description of change (include <br />Amendment for PSA for MPAC. <br />budget impact) <br />APPROVED BY PROJECT <br />(PAT member's name and date to be completed by PAT member) <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) <br />(PAT member's name and date to be completed by PAT member) <br />PO Number <br />Line Number <br />Original Dollar Amount <br />PO-0013835 - Change Order Request Form 1 of 3 <br />