Specifics

Vendor Name*

Contract Title*

Original Town Contract #*

Purpose*

Change Order (Amendment) Extend Expiration Date of Current Contract Extension Year Option Termination

New Town Contract # (if applicable)

New Expiration Date (if applicable)

Change Order # (if applicable)

Enter dollar amounts ($ 00,000.00)

Original Contract Value*

Value of Previous Change Orders

(please check your math)

Value of this Change Order

Revised Contract Value*

(please check your math)

# of Original Copies*

Did the Vendor sign all copies?*

Yes

No

Department*

Building Design & Construction Department DPW – General Fund Operating Budget All Divisions DPW - General Fund Capital Project All Divisions DPW - Sewer Operating & Capital DPW - Water Operating & Capital Finance Department - General Finance Department - Technology Fire Department Human Resources Health and Human Services Building Department Library Park & Recreation Planning and Community Development Police Department Town Clerk Town Manager

Attachments

Please indicate which documents have been attached to the contracts.

Supporting Documentation*

Yes

No

Updated Prevailing Wage Schedule*

Yes	Not Applicable

Updated Certificate of Insurance*

Yes	Not Applicable

Updated Payment Bond*

Yes	Not Applicable

Updated Performance Bond*

Yes	Not Applicable

Other Documents*

Yes

None

Updated W-9 Form*

Yes

No

Accounting Details

Certification of funds required?*

Yes

No

Is the total amount to be encumbered? *

Yes No - more than one Operating Budget year No - not a guaranteed contract No - on-call only Not Applicable (Revenue or Zero $ Contract)

Indicate below the account number(s)and amount(s) to be encumbered
(please check your math).

Account #

$ Amount

Account #

$ Amount

Account #

$ Amount

Account #

$ Amount

If applicable, indicate the Purchase Order # to be amended and the expiration date for the amended Purchase Order

PO # to be Amended

Reserved

Authorization Code*

rev 08/22/2011; 06/11/2014; 11/23/2015; 08/25/2017; 12/17/2019; 08/17/2021