(HUD-51002) Schedule of C.O.s.pdf

OMB Approval No. 2577-0157 (exp. 11/30/2023) Schedule of

Change Orders

U.S. Department of Housing and Urban Development Office of Public and Indian Housing

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD may not conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number.

This information is collected under the authority of Section 6(c) of the U.S Housing Act of l937 and HUD regulations. HAs are responsible for contract administration to ensure that the work for project development is done in accordance with State laws and HUD requirements. The contractor/subcontractor reports provide details and summaries on payments, change orders, and schedule of materials stored for the project The information will be used to ensure that the total development costs, identified in the ACC, are kept as low as possible and consistent with HUD construction requirements. Responses to the collection are necessary to obtain a benefit. The information requested does not lend itself to confidentiality.

Instructions: Contractors use this form for reporting the details of approved Change Orders. Attach an original (or a opy) to each copy of the Periodic Estimate for Partial Payment (form HUD-51001) submission, and send to the Public Housing Agency. Complete all entries. Only Change Orders which bear the signatures required by the contract are to be recorded.

Name of Public Housing Agency Supporting Periodic Estimate for Partial Payment Number

Period

From (mm/dd/yyyy) to (mm/dd/yyyy) form HUD-51002 (1/2014) Previous editions are obsolete.

I certify that the information provided on this form and in any accompanying documentation is true and accurate. I acknowledge that making, presenting, or submitting a false, fictitious, or fraudulent statement, representation, or certification may result in criminal, civil, and/or administrative sanctions, including fines, civil penalties, and confinement for up to 5 years, (18 U.S.C. §§ 287, 1001 and 31 U.S.C. §3729)

Approved Change Orders Additions Deductions

Change Order Number

Dated (mm/dd/yyyy)

Total Amount of Change Order

Value of Work Completed to Date

Total Amount of Change Order

(1) (2) (3) (4) (5)

Totals $ $ $

Authorized Project Representative Date (mm/dd/yyyy)

Location of Project Project Number

Name of Contractor Contract Number