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1103 <br />Texas Department of Rural Affairs <br />Construction Contract Change Order Approval Request <br />OWfI@f (Contractor Locality): <br />(Name 8 Address) <br />Phone <br />COI1tC'aCt FOf (project description): <br />Dat@ <br />Project No. <br />Contractor: <br />(Name & Address) <br />Agreement Date: <br />Phone <br />Engineer: <br />(Name & Address) <br />Phone <br />En ineer's Pro'ect No. <br />TxCDBG Contract No. <br />Change Order No. <br />You are hereb re uested to com i <br />with the followin chan es from the contract lans and s eccations: <br />Item <br />No. <br />Description of Changes-Quantities, Units, Unit Prices, <br />Chan e in Com letion Scheduled, Etc. <br />Decrease in <br />Contract Price <br />Increase in <br />Contract Price <br />Chan e in Contract Price <br />Chan e in Contract Time <br />Ori inal Contract Price: <br />$ <br />Ori inal Contract Time: da s <br />Previous Change Order(s) <br />No. to No. <br />$ <br />Net Change From Previous <br />Chan e Orders da s <br />Contract Price Prior to <br />this Chan e Order <br />$ <br />Contract Time Prior to <br />this Chan e Order da s <br />Net Increase/Decrease of <br />this Chan e Order <br />$ <br />Net Increase/Decrease of <br />this Chan e Order da s <br />Contract Price With all <br />A roved Chan e Orders <br />$ <br />Contract Time With all <br />A roved Chan e Orders da s <br />Cumulative % Change in Contract Price: <br />% <br />TxCDBG reimbursement of costs approved by this change order is subject to approval by the Office. <br />RECOMMENDED: <br />By: <br />ENGINEER (Authorized Signature) <br />Date: <br />APPROVED: <br />By: <br />OWNER (Authorized Signature) <br />Date: <br />ACCEPTED: <br />By: <br />CONTRACTOR (Authorized <br />Signature) <br />Date: <br />51 <br />