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A UTHORIZATION OF C HANGE IN S ERVICE <br />CONTRACT NAME:NUMBER: <br />CONTRACTOR: <br />ORIG. CONTRACT DATE:RESOLUTION NO: <br />CITY REPRESENTATIVE:DEPT: <br />DATE:ACIS NO.: <br />DESCRIPTION OF WORK TO BE ADDED TO OR DELETED FROM SCOPE OF SERVICES: <br />Original Contract Amount:$ <br />Previous Increasesin Contract Amount:$ <br />CURRENT CONTRACT AMOUNT:$ <br />This Increasein Contract Amount:$ <br />REVISED CONTRACT AMOUNT:$ <br />C ONTRACTOR: <br />SignatureDate <br />Print Full Name /Title (if not in individual capacity) <br />C ITY: <br />SignatureDate <br />_______________________________________________________________ <br />Print Name/ Title <br />City Department Use Only Below This Line (PM, POC, etc.). <br />Account Number(s):AmountDate <br />#$ <br />#$ <br />#$ <br />02/21/17Rev. 05.25.2021 Page 1of 1 <br />Page 22 of 44 <br /> <br />