Change Order Request Form - Draft

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CHANGE ORDER REQUEST FORM
CONTRACT NO.
DATE OF SUBMISSION
PROJECT DESCRIPTION
(route / intersection / bridge no(s).)
CHANGE ORDER REQUEST SUMMARY
DESCRIPTION
PROPOSED SOLUTION SUMMARY
NOTE: Upon request from Engineer, enter detailed description on page 2.
ONSET DATE OF CHANGE
PROPOSED COST AND TIME ADJUSTMENT
COST INCREASE / (DECREASE):
$
COST
The cost adjustment shall include lump sum and estimated totaled unit-priced item costs. Attach a separate sheet of unit price items
including item description, unit of measurement, estimated quantity and unit price.
CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF COST CHANGE:
☐ 109.03 Altered Quantities
☐ 109.05(a) Agreed Price ☐ 109.05(b) Force Account
☐ 109.05.02 Delay Costs
PROPOSED COST CHANGE INCLUDES: ☐ Labor ☐ Material ☐ Equipment ☐ Lease Agreement ☐ Subcontractor
TIME ADJUSTMENT
INCREASE / (DECREASE):
(work days)
CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE:
☐ 108.08(b) Excusable, Compensable
☐ 108.08(a) Excusable, Non-Compensable
NOTE: If Compensable, attach details based on 109.05.2(a) Allowable Delay Costs.
SUPPLEMENTAL INFORMATION
Additional information may be entered by the contractor.
☐ Contractor
CHANGE ORDER ORIGINATION:
☐ INDOT / LPA
DOCUMENTS AFFECTED:
☐ Contract Specifications (ref. doc name/no.)
☐ Contract Plans (ref. doc name/no.)
☐ yes ☐ no (if yes, attach details)
CHANGE ORDER AFFECTS DBE PARTICIPATION:

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