ABSTRACT

Description of Event that Caused Claim: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Description of Change: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

References: _________________________________________________________________________ _________________________________________________________________________

LUMP-SUM BREAKDOWN>

LUMP-SUM BREAKDOWN (CONTINUED)

SCHEDULE OF VALUES

SCHEDULE OF VALUES (CONTINUED)

SCHEDULE OF VALUES (CONTINUED)

DESCRIPTION OF EFFECT OF ADJUSTMENT

Effect of this adjustment in the Work on the Facility and Baseline Level 3 Schedule (if none, so state): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Effect of this adjustment in the Work on the Completion Guarantees (if none, so state): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Effect of this adjustment in the Work on the Performance Guarantees (if none, so state): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Effect of this adjustment in Work on the Functional Specifications (if none, so state): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

CLAIM FOR ADJUSTMENT CLAIM NO:_______ AREA:__________ REVISION:________ DATE:________ PAGE __ OF __

DESCRIPTION OF EFFECT OF ADJUSTMENT (CONT’D)

For this Adjustment, the payment criteria and schedule are: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

ISSUED BY CONTRACTOR <<insert date>> By:___________________________ Name: Title:

ACCEPTED/REJECTED BY SPONSOR <<insert date>> By:___________________________ Name: Title:

CLAIM FOR ADJUSTMENT NOTES TO CLAIM FOR ADJUSTMENT

Direct Field Costs (Cost Codes 401-474)

Material: All materials, supplies, and equipment which are for permanent installation in the Facility. The cost of equipment and material includes invoice cost, inland transportation, insurance, handling costs, permits, licenses and permitted markups per Appendix 1 for overhead and profit. Applicable export charges, ocean freight, and taxes shall be included as line items under “Construction Indirect Cost.” Cost for Contractor supplied spare parts prior to Facility Provisional Acceptance are not included here but under cost code 516, “Initial Spare Parts.”