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CHANGE ORDER REQUEST FORM <br />CONTRACT 0 DATE OF September <br />NO. SUBMISSION 22,2020 <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />ONSET DATE OF CHANGE September_.1, 2020 CHANGE ORDER TYPE F 104.03 Extra Work <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST <br />COST INCREASE / (DECREASE): <br />$ 565.19: <br />The cost adjustment shall include lump sum and estimated totaled unit -priced item costs. Attach a separate sheet of unit price items <br />including item description, unit of measurement, estimated quantity and unit price. <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF COST CHANGE: <br />D 109.03 altered Quantities Q t.09 05(a) Agreed Pnce Z 109.05(b) Force Account {] 109.05.02 Delay Costs. <br />PROPOSED COST CHANGE INCLUDES: Cl Latior Material ; Equipment . ❑Leas*' Agreement <br />Subcontractor <br />TIME ADJUSTMENT INCREASE / (DECREASE): (work days) N/A <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />0 108.08(a) Excusable Non-CAmpensable-0108.08(b) Excusable, Corn erasable <br />NOTE: if Compensable, attach details based on 109.05.2(a) Allowable Delay Costs. <br />SUPPLEMENTAL INFORMATION <br />Additinnal lnfnrmatinn may hn entered by the nnntrartnr <br />CHANGE ORDER ORIGINATION: <br />,® .INDOT/-LPA ❑ Contractor . <br />DOCUMENTS AFFECTED: <br />❑ Contract Sped icatlons (ref. doc name/no.) <br />Caick here to enter <br />❑ Contract Plans (ref. doc name/no.) <br />Click here W enter text <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />❑.yes ® no..(Ifyes, attach details) ' <br />Ver. 10.23.17 <br />