216 Construction and Change Order

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0572-0059.. The time required to complete this
information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.
Expires: XX/XX/20XX

DATE
DEPARTMENT OF AGRICULTURE
RURAL UTILITIES SERVICE

PROJECT

CONSTRUCTION CHANGE ORDER

ORDER NO.

LINE

SHEET NO.

POLES NO.

REFER TO ITEM NO.

CHANGE

REASON FOR CHANGE

CHANGE AUTHORIZED BY:

SYSTEM MANAGER

BORROWER'S ENGINEER

ITEMIZED COST OF ABOVE ORDER

CONTRACTOR

RUS Form 216 (Rev. 7-67)