Change Order No 1 - VPA Athletic Courts Renovations, Phase III Proj No. 123-040 - Milestone

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City of South Bend Department of Administration & Finance Change Order Request Form Multiple PO lines: Project POs: PO Number 24691 Line Number Add line #2 Original Dollar Amount $0.00 New Dollar Amount (For liquidation request, enter $0)$10,846.55 Reason Code (if changed)SV-ES Financial Dimensions (fund-dept- division-subdivision-main account)201-11-206-273-445003--PROJ00000414 Project Code (if applicable)PROJ00000414: Project Category 201-445003 Description of change (include budget impact)PR was not adjusted to the approved award amount prior to BPW award APPROVED BY PROJECT ACCOUNTING TEAM (if applicable)(PAT member's name and date to be completed by PAT member) PO Number 24691 Line Number Add line #3 Original Dollar Amount $0.00 New Dollar Amount (For liquidation request, enter $0)$44,212.50 Reason Code (if changed)SV-ES Financial Dimensions (fund-dept- division-subdivision-main account)201-11-206-273-445003--PROJ00000414 Project Code (if applicable)PROJ00000414: Project Category 201-445003 Description of change (include budget impact)Change Order #1. For alternate resurfacing for Keller athletic court. APPROVED BY PROJECT ACCOUNTING TEAM (if applicable)(PAT member's name and date to be completed by PAT member) PO Number Line Number Original Dollar Amount Changing the line amount: You can only change a line amount if it has NOT been invoiced against. • If the line has NOT been invoiced – reduce the line amount to equal what it should be. • If the line has been invoiced – cancel the delivery remainder and finalize the individual line, then add a new line for the amount that should be remaining. 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 order. For change orders on project-related POs, this form must be approved by the Project Accounting Team as described in Supplement 508. PO24691- Change Order Request Form 1 of 3