CONTRACTOR CHANGE ORDER REQUEST SUMMARY

Project Name:
Project NO:

C.O.R. NO:
Date:
Prime Contractor:
Description of Change:

A
B
C

Prime Contractor Direct Costs

Additive Costs
Labor
Material
Equipment

Subtotal of Additive Cost

E
F
G

Deductive Costs (Use parenthesis to denot negative figures)

Labor
Material
Equipment

Subtotal of Deductive Cost

Contractor's Total Direct Cost (D+H)

General Contractor's Mark-up

Total Prime Contractor Direct Costs + Mark-up (Line I + J)

Total Subcontractor Direct Costs

Subcontractor Mark-up

General Contractor's Mark-up on Subcontractor Direct Costs

Total General Contractor Change Request (Lines K + L + M + N)

To the best of my knowledge and belief, I certify that all costs listed abve are correct.

Contractor Signature

Date