CONTRACT CHANGE REQUEST/AUTHORITY (CCR/A)
NJSDA Form 500
NJSDA Form 500
Page 1 of 3
Revised: March 2012
CCR/A No.:
Date:
Contract No.:
Contractor
Name:
PMF/CM:
PMF/CM/PM:
CCR/A No.:
RFI No.:
School Name:
NJSDA Region:
District Name:
Time and Material
Lump Sum Proposal (Unit Costs)Lump Sum Proposal (Hrs., Materials, & Equipment)
Please submit an itemized proposal for changes in the Contract Sum and/or Time incidental to proposed modifications to the Contract
Documents described herein.
THIS IS NOT A CHANGE ORDER NOR A DIRECTION TO PROCEED WITH THE WORK DESCRIBED HEREIN.
Description:
Design Consultant Firm:
CONTRACT CHANGE REQUEST/AUTHORITY (CCR/A)
NJSDA Form 500
NJSDA Form 500
Page 2 of 3
Revised: March 2012
CCR/A No.:
Justification: (Reason for Change)
Cause/Reason:
Owner Initiated
Differing Site Conditions
Design Consultant E/O (Change Orders Only)
CONTRACT CHANGE REQUEST/AUTHORITY (CCR/A)
NJSDA Form 500
NJSDA Form 500
Page 3 of 3
Revised: March 2012
CCR/A No.:
Attachment: (Include RFI, Bulletin, or any other document supporting this CCR/A)
FirmPrint Name
Signature
Requested By:
Date
Print Form