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U.S. Department of Transportation
Federal Highway Administration
RECORD OF AUTHORIZATION TO PROCEED WITH MAJOR CONTRACT REVISION
PROJECT NO.
 
COUNTYSTATE
TYPE OF REVISION
check box CHANGE ORDER
check box WORK ORDER
check box SUPPLEMENTAL AGREEMENT
check box OTHER:
check box TIME EXTENSION check box SPECIFICATION CHANGE
REQUESTED BY
 
DATE
NATURE OF AND REASON FOR PROPOSED REVISION (If additional space is required, use reverse side)
ESTIMATED
check box INCREASE
check box DECREASE
IN COST: $ _________
METHOD OF PAYMENT
check box FORCE ACCOUNT
check box UNIT BID PRICES
check box NEGOTIATED PRICE
check box OTHER:
check box LUMP SUM
THE WORK COVERED BY THE PROPOSED REVISION AS DESCRIBED ABOVE IS HEREBY AUTHORIZED SUBJECT TO THE CONDITIONS MARKED BELOW:
check box EVALUATION OF COST DATA
check box LIMITATIONS OF EXTENT OF FEDERAL PARTICIPATION
check box DETERMINATION OF SATISFACTORY ADJUSTMENT IN TIME
check box ADEQUATE SUBMITTAL OF WRITTEN SUPPORTING DATA
check box PROPOSED REVISION AUTHORIZED WITHOUT FEDERAL PARTICIPATION
check box OTHER (Explain)
check box 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

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Contact

Jerry Yakowenko
Office of Program Administration
202-366-1562
E-mail Jerry

 
Updated: 04/07/2011
 

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United States Department of Transportation - Federal Highway Administration