RUS Form 216 - Construction 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.

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)

OMB Control No. 0572-0059
Expiration Date: November 2020