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U.S, Department of Housing OMB Approval No. 2577-0157
Schedule of and Urban Development (exp. 1/31/2027)
Change Orders 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 deta
sources, gathering and maintaining the data needed, and completing and reviewing the ccllection of information. HUD may not conduct or sponsor, and an applicant is not
Tequired to respond to a collection of information unless it displays a currently valid OMB centrol number. Comments regarding the accuracy of this burden estimate and any
suggestions for reducing this burden can be sent to the Reports Management Officer, Office of Policy Development and Research, REE, Department of Housing and Urban
Development, 451 7th St SW, Room 4176, Washington, DC 20410-5000. When providing comments, please rafer to OMB Approval No. 2577-0157. This information is
collected under the authority of Section 6(c) of the U.S Housing Act of 1937 and HUD reguletions. HAs are responsible for contract administration to engure 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 cosis, identified in the ACC,
are kept as low as possible and consistent with HUD construction requirements. Responses to the collection are necessary to cbtain a benefit. The information requested
dogs not lend itself to confidentiality.
Instructions: Contractors use this form for reporting the detalls of approved Change Orders. Aftach an original (or a opy) ta 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 Period
for Partial Payment Number IFrom (mmvdld/yyyy) to (mmiiddiyyyy)
Location of Project Projed Namiber
Name of Contractor Contract Number
Approved Change Orders Additions Deductions
Change Order Dated Total Amount Value of Work Total Amount
Number (mmiddiyyyy) of Change Order Completed to Date of Change Order
th @ is] @ 8
$ $ $
Totals $ $ $
Authorized Project Representative Date (mmiddlyyyy)
I certify that the information provided on this form and in any accompanying documentation is true and accurate. | acknowledge that making, presenting, or
submitting a false, fictitious, or fraudulent staternent, 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)
Previous editions are obsolete. form HUD-51002 (1/2014)Jump to an indexed page (88 of 88)