216 Construction Change Order

OMB No. 0572-0059
Expires: xx/xx/20xx
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to the requirements of the Paperwork Reduction Act unless that collection of
information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 0572-0059. Public Reporting for this collection of information is estimated to
be approximately 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the
collection of information.
All responses to this collection are voluntary. However, in order to obtain or retain a benefit, the information in this form is required. Rural Development has no plans to publish information
collected under the provisions of this program. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to:
Information Collection Clearance Officer, Rural Development Innovation Center, Regulations Management Division at [email protected].

DEPARTMENT OF AGRICULTURE

DATE

RURAL UTILITIES SERVICE

CONSTRUCTION CHANGE ORDER
PROJECT

LINE

SHEET NO.

ORDER 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. 4-2024)