Construction Change Order Payment Application
Project Name
Project Number
Owner
Contractor
Change Order No.
Date
Change Order Details
Description of Work
Reference
Original Amount
Added Amount
Deducted Amount
Net Change
Summary of Payment
Original Contract Amount
Net Change By Change Orders
Total Contract Amount
Total Completed & Stored to Date
Less Previous Certificates for Payment
Current Payment Due
Balance to Finish
Remarks / Notes
Contractor's Signature
Owner's Signature
Date