Form 216 - Construction Change Order

RUS Form 216-Construction Change Order.pdf

The Rural eConnectivity Pilot Program ( ReConnect Program).

Form 216 - Construction Change Order

OMB: 0572-0152

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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
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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


File Typeapplication/pdf
File Titlerus0216.fml
AuthorMBrooks
File Modified2018-11-15
File Created2003-02-28

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