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Appendix A: Change Order Form <br />Change f rder Chauge Order Date <br />Change Requestoir Information <br />Company Name <br />City of South Bend <br />Name & Title <br />Phone <br />Email <br />Description of Requested Change <br />NOTE: Change Orders must be reviewed and authorized by CSA for acceptance of the requested change. Changes to the scope of <br />an implementation may require additional software components and/or Professional Services to make the requested change <br />operational - where this may result in additional costs. <br />Additional software components required: Yes 0 No 0 Additional Professional Services required; Yes 0 No El <br />This document is the property of and Is proprietary to Canon Solutions America. it is not to be disclosed in Page 22 <br />-,aliffli whole or In part without prior written consent of Canon Solutions America, and shall not be dupficated or used in SER-03S <br />CANON SOLUIIONSAMWCA whole or in part, for any purpose other than to evaluate Canon Solutions America's proposal, and shall be returned <br />upon request. December 30, 2016 <br />