Change Order Form

OMB Control No. 0610-0096
Expiration Date: xx/xx/20xx

ECONOMIC DEVELOPMENT ADMINISTRATION
CHANGE ORDER FORM
EDA Award Number:

Date:

Recipient:
Co-Recipient(s):
Recipient’s Authorized Representative:
Name & Phone Number
Construction
Contract No.

Change Order
No.

Contractor Name

The Change Order will provide for the following:

Change Order Justification (Include cost analysis, if not unit cost in bid proposal or schedule of values):

TOTAL

Original Contract Amount
Current Contract Amount adjusted by
previous Change Orders
This Change Order will
_______(increase) _______(decrease)
the Contract Amount by:
The original, scheduled date of
completion is/was:
The new Contract Amount including
this Change Order will be:
The Contract Time will
_______(increase) _______(decrease)
the schedule by:
The estimated date for completion of all
work is:

EDA Funded Amount

* Non-EDA Funded Amount

$

$

$

$

$

$

$

$

$

$

$

$

calendar days

calendar days

calendar days

(Date)

(Date)

(Date)

* Construction components not part of the EDA Grant Project and do not include EDA funds nor local match funds.

Prepared By (Signature)

Date

Prepared By (Typed or Written Name & Title)
Page 1 of 1