Change Order No 4 - Coal Line Trail, Phase IIB Proj No. 122-035 - INDOT Milestone

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City of South Bend Department of Administration & Finance Change Order Request Form 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. Multiple PO lines: 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. Project POs: For change orders on project -related POs, this form must be approved by the Project Accounting Team as described in Supplement 508. PO Number PO-25244 Line Number 6 Original Dollar Amount new line New Dollar Amount $7,381.52 For liquidation request, enter $0 Reason Code if changed) SV Financial Dimensions (fund-dept- 324-444000 division -subdivision -main account Project Code if applicable) PROJ-00000018 Description of change (include add $7,381.52 for drinking fountain installation on Coal Line Trail Phase 1113 bud et impact) APPROVED BY PROJECT (PAT member's name and date to be completed by PAT member) ACCOUNTING TEAM (if applicable) PO Number Line Number Original Dollar Amount New Dollar Amount For liquidation request, enter $0 Reason Code if changed) Financial Dimensions (fund-dept- division-subdivision-main account Project Code if applicable) Description of change (include budget impact) 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 CO#4 CLT 1113 - DFO Balancing Change Order 1 of 3