State Form 828 - Advice Of Change In Purchase Order - Indiana Department Of Administration
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1
2
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4
5A DVICE OF C HANGE
This page number
Total number of pages
O
VENDOR NOTICE: Match this document
IN PURCHASE ORDER
F
with the Purchase Order described below.
Issued by State of Indiana
Purchase Order / Change number
State Form 828 (R 4 / 3 -00)
Purchase Order date Required delivery date
P0 -
Approved by State Board of Accounts - 1992
AC-
RECYCLED PAPER
I.D.O.A. identification number
Fund / Object / Center (use all 16 digits)
Original to vendor
1
Account / Project number
Federal I.D. number of vendor
Name & address
of vendor
Reporting code
Name of requesting agency / Approp. name
F OR AUDITO R O F S TATE
Verified by:
Changed by:
Ship to:
Funds available
CONTRACT TERMS
Attached to original Purchase Order
The contract terms and conditions
contained in the original Purchase
Order remain the same, except to the
Amended amount of Purchase Order
extent modified below.
NOTICE: No price corrections will be permitted after issuance of this Advice of Change.
Contract
Line
QUANTITY
QUANTITY
ARTICLE and DESCRIPTION
UNIT PRICE
AMOUNT
UNIT
I tem
RECEIVED
ORDERED
No.
+
NET INCREASE
-
NET DECREASE
Signature of purchasing administrator
Typed name
FUNDING ENCUMBERED BY THE AUDITOR OF STATE
I certify that there is a sufficient unencumbered balance
in the above account to cover the amount of the original
Date signed
Purchase Order as amended hereby, and that funds have
been set aside for payment thereof.
Authorized signature, Auditor of State
Date signed
Indiana Department of Administration
Procurement Division
402 West Washington Street, Rm W468
Indianapolis, Indiana 46204
Telephone: (317) 232-3053
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