U.S. Department of Transportation Federal Highway Administration	RECORD OF AUTHORIZATION TO PROCEED WITH MAJOR CONTRACT REVISION
PROJECT NO.		COUNTY		STATE
TYPE OF REVISION CHANGE ORDER WORK ORDER SUPPLEMENTAL AGREEMENT OTHER: TIME EXTENSION SPECIFICATION CHANGE
REQUESTED BY				DATE
NATURE OF AND REASON FOR PROPOSED REVISION (If additional space is required, use reverse side)
ESTIMATED INCREASE DECREASE IN COST: $ _________			METHOD OF PAYMENT FORCE ACCOUNT UNIT BID PRICES NEGOTIATED PRICE OTHER: LUMP SUM
THE WORK COVERED BY THE PROPOSED REVISION AS DESCRIBED ABOVE IS HEREBY AUTHORIZED SUBJECT TO THE CONDITIONS MARKED BELOW: EVALUATION OF COST DATA LIMITATIONS OF EXTENT OF FEDERAL PARTICIPATION DETERMINATION OF SATISFACTORY ADJUSTMENT IN TIME ADEQUATE SUBMITTAL OF WRITTEN SUPPORTING DATA PROPOSED REVISION AUTHORIZED WITHOUT FEDERAL PARTICIPATION OTHER (Explain) NONE
RECOMMENDED BY AREA ENGINEER			DIVISION OFFICE APPROVAL
SIGNATURE		DATE	SIGNATURE		DATE

Form FHWA-1365 (Use Reverse for Comments, if Required)
(Rev. 3-86) PREVIOUS EDITIONS MAY BE USED