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Requestor Data <br />Project Name: <br />Date of Change Request: <br />Change Request Summary <br />Urgency: ❑ Low ❑ Medium <br />(Circle One) ❑ High ❑ Critical <br />Reason for <br />change: <br />Describe change: <br />Impact if rejected: <br />Current status: <br />Timeline Impact <br />Project Completion Date: <br />Milestone(s) Affected: <br />New Milestone Date(s): <br />Cost Estimate <br />Requesting Party: <br />Prepared By: <br />Nature of Change: ❑ Scope ❑ Schedule <br />(Choose o0 the apply) ❑ Budget ❑ Performance <br />All cost estimates are provided for budgetary purposes only. At the completion of this change request and/or the total <br />project, actual cost amounts based on hours worked will be billed. <br />Resource Function Hourly Rate <br />Insert Name Project management $xx <br />Insert Name Technical assistance $xx <br />Approval <br />Signature of this form indicates acceptance of the change request form as an amendment of the previously signed project <br />plan. <br />Signature <br />Printed Name <br />Date <br />Title <br />Statement of Work for City of South Bend 13 <br />