Form Center

2. Specifics
4. 
   
6. Vendor Name*
8. Contract Title*
10. Original Town Contract #*
12. Purpose*
    -- Select One --Change Order (Amendment)Extend Expiration Date of Current ContractExtension Year OptionTermination
14. New Town Contract # (if applicable)
16. New Expiration Date (if applicable)
18. Change Order # (if applicable)
20. Enter dollar amounts ($ 00,000.00)
22. Original Contract Value*
24. Value of Previous Change Orders
25. (please check your math)
27. Value of this Change Order
29. Revised Contract Value*
30. (please check your math)
32. # of Original Copies*
34. Did the Vendor sign all copies?*

    1. Yes
    2. No
36. Department*
    -- Select One --Building Design & Construction DepartmentDPW – General Fund Operating Budget All DivisionsDPW - General Fund Capital Project All DivisionsDPW - Sewer Operating & CapitalDPW - Water Operating & CapitalFinance Department - GeneralFinance Department - TechnologyFire DepartmentHuman ResourcesHealth and Human ServicesBuilding DepartmentLibraryPark & RecreationPlanning and Community DevelopmentPolice DepartmentTown Clerk Town Manager
38. 
    
40. Attachments
42. Please indicate which documents have been attached to the contracts.
44. Supporting Documentation*

    1. Yes
    2. No
46. Updated Prevailing Wage Schedule*

    1. Yes
    2. Not Applicable
48. Updated Certificate of Insurance*

    1. Yes
    2. Not Applicable
50. Updated Payment Bond*

    1. Yes
    2. Not Applicable
52. Updated Performance Bond*

    1. Yes
    2. Not Applicable
54. Other Documents*

    1. Yes
    2. None
56. Updated W-9 Form*

    1. Yes
    2. No
58. 
    
60. Accounting Details
62. 
    
64. Certification of funds required?*

    1. Yes
    2. No
66. Is the total amount to be encumbered? *
    -- Select One --YesNo - more than one Operating Budget yearNo - not a guaranteed contractNo - on-call onlyNot Applicable (Revenue or Zero $ Contract)
68. 
    
70. Indicate below the account number(s)and amount(s) to be encumbered
    (please check your math).
72. 
    
74. Account #
75. $ Amount
77. Account #
78. $ Amount
80. Account #
81. $ Amount
83. Account #
84. $ Amount
86. 
    
88. If applicable, indicate the Purchase Order # to be amended and the expiration date for the amended Purchase Order
90. 
    
92. PO # to be Amended
94. Reserved
96. 
    
98. Authorization Code*
100. rev 08/22/2011; 06/11/2014; 11/23/2015; 08/25/2017; 12/17/2019; 08/17/2021
Leave This Blank:


102. Submit Submit and Print

* indicates a required field