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TEXAS DE~RTMENT OF TRANS~RTATION <br />CHANGE ORDER NUMBER 4 (Supporting Supplements/ Agreement No. N/A 1 <br />Third Party Funding Information <br />This form is used when the subject change order involves funding by a source other than TxDOT. <br />1. Outside funding provided by: <br />City of LaPorte <br />(Third-Party's Legal Name) <br />2. Is there an existing agreement for outside funding? <br />[X] Yes [ ] No <br />If yes, does this change order modify the scope of work included <br />in the original funding agreement? <br />[ ] Yes [X] No <br />3. Indicate the type and amount of funding: <br />[ ] Fixed Sum (Amount 5 <br />(X] Actual Cost <br />Contract Items 56,947.30 <br />E&C -( 7.00 %) $ 486.31 <br />Subtotal 57,433.61 <br />Indirect Cost ( 8.41 %) 5 625.17 <br />TOTAL $8,058.78 <br />I hereby approve the modifications covered <br />by the attached Form CO for this change <br />order and agree to finance the additional <br />costs, if any, as reflected by this form. <br />By <br />Date <br />(Typed/Printed name) <br />(Title) <br />For Division Use Only: <br />Change Order Approved by <br />Construction and Maintenance Division Field Engineer <br />Date <br />An executed agreement and required funds have been received to cover the referenced change <br />order: <br />General Services Division <br />Date <br />TxDOT Form CO-2EA <br />1-94 <br />