Purchase Order Change Form

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PURCHASE ORDER CHANGE FORM
Purchase Order #:_________________Req. #:_______________Original P.O. Date:_______________
Vendor:__________________________________________Vendor #:___________________________
Department:______________________________________Account #:__________________________
Reason for Change:
_________________________________________________________________
_________________________________________________________________
Type of Change: (Please check one)
_____
Change Account Number – for all lines YES____ NO____ If no, specify line number______________
-
Original Account Number
__________________________________________________
-
Revised Account Number
__________________________________________________
______ Increase Purchase Order
-
Quantity
__________________________
Amount ____________________________
Line Numbers
________________________________________________________________
______ Decrease Purchase Order
-
Quantity
__________________________
Amount ____________________________
Line Numbers
________________________________________________________________
(* For City only, decrease only if Purchase Order has a change to the contract or estimated funds.)
______ Cancel Purchase Order – for all lines YES____
NO____
-
Total Amount to be Cancelled
$_________________________
______ Cancel Purchase Order Line(s)
Amount $__________________________ Line Numbers_______________________________
(* Only cancel purchase orders that have had no payment applied against them.)
If this is a change to a contract, please indicate Board _______________________and date approved________.
Original Purchase Order Total Amount:
$__________________________________________
Previous Purchase Order Total Amount:
$__________________________________________
(If Purchase Order has previously been changed, provide the total amount of the most recent change order including all prior change orders.)
Current Change Order Amount:
$__________________________________________
(This amount should equal the amount reflected above, under Type of Change section.)
Revised Purchase Order Total Amount:
$__________________________________________
Signed: ______________________________________________________
Date: ________________________
(Department Head/ Authorized Representative)
Auditor/ Finance Approval ______________________________________
Date: ________________________
Budget Hold Override Authorization by: ___________________________
Date:________________________
Purchase Order Change Notices are reviewed to determine conformance to established Purchasing guidelines. All Change Notices must adhere to
relevant agreements. bids, contracts and guidelines.
Revised: July 2007
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