Change Order
Contractor (Name and Address):
___________________________________________________________________________________________
Change Order No.:___________________________________________
Contract No.:_______________________________________________
Project No.:________________________________________________
Description and Location of Work:_________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Original Amount of Contract:__________________________________
Approved C.O. Amount to Date:_______________________________
Present C.O. Amount:_______________________________________($0.00)
Revised Contract Amount:___________________________________($0.00)
Description of Change 1
_______________________________________________________________________Total_________________________________________
Description of Change 2
_______________________________________________________________________Total_________________________________________Description of Change 3
_______________________________________________________________________Total_________________________________________Description of Change 4
_______________________________________________________________________Total_________________________________________Description of Change 5
_______________________________________________________________________Total_________________________________________Description of Change 6
_______________________________________________________________________Total_________________________________________Description of Change 7
_______________________________________________________________________Total_________________________________________Description of Change 8
_______________________________________________________________________Total_________________________________________Description of Change 9
_______________________________________________________________________Total_________________________________________Description of Change 10
_______________________________________________________________________Total_________________________________________Description of Change 11
_______________________________________________________________________Total_________________________________________Description of Change 12
_______________________________________________________________________Total_________________________________________Description of Change 13
_______________________________________________________________________Total_________________________________________Description of Change 14
_______________________________________________________________________Total_________________________________________Description of Change 15
_______________________________________________________________________Total_________________________________________Description of Change 16
_______________________________________________________________________Total_________________________________________Description of Change 17
_______________________________________________________________________Total_________________________________________
Description of Change1 -17_total
Total:_______________________________
Recommended: _______________________________________
Signature: ___________________________________________
Date (YYYY-MM-DD):__________________________________
2nd Signature (if applicable): ___________________________________________
Date (YYYY-MM-DD)2:_________________________________
Approved:___________________________________________
Signature: ___________________________________________
Date (YYYY-MM-DD)3:_________________________________
Contractor (Name and Address)2: _______________________________________
Change Order No.2:___________________________________________________
Contract No.2:_______________________________________________________
Project No.2:________________________________________________________
Description and Location of Work 2:_______________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Reasons for Change:___________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Category:
Select one or more values
AC Client requested changes to OGD funded projects ______________
AD Dominion or Regional Fire Commissioner required changes________________
AF Facilities Maintenance requested changes to PWGSC ______________
AP Property Management requested changes to PWGSC________________
AR Regulatory Agencies, other than DFC/RFC, required changes to conform to codes and statutes________________
BD Delay or negligence on the part of the Crown resulting in a claim from the Contractor______________
BS Soil conditions different from those specified_____________
BT Federal Tax, duty or tariff changes during the contract period_____________
BU Unit price changes due to quantities, and Balancing Change Orders_____________
CE/O Design Errors or Omissions costs, items that could or should have reasonably been foreseen_____________
CM Material Substitution initiated by Crown or Contractor_____________
CS Site condition costs resulting from items that could not have reasonably been foreseen_____________
CT Acceleration or deferment of part of the work requested by the Crown (not a time extension or delay claim initiated by the Contractor)___________
A Client requested changes_____________
B Errors and omissions_____________
C Unforeseen site conditions_____________
D Substitution of materials_____________
E Price and quantity fluctuations____________
F Delays, acceleration, suspension_____________
G Other____________
L Inducement (Lease)___________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Pursuant to section 32(1) of the Financial Administration Act, funds are available.
Signature (Mandatory): ___________________________________________
Date (YYYY-MM-DD)4:___________________________________________
http://www.tpsgc-pwgsc.gc.ca/app-acq/forms/610-eng.html
