I, THE UNDERSIGNED CONTRACTOR DO HEREBY CERTIFY THAT I HAVE REVIEWED MY FILES AND DECLARE THAT THERE ARE/ARE NOT (CIRCLE ONE) NEW OR ADDITIONAL SUBCONTRACTORS AND SUBCONTRACTORS WHICH ARE REQUIRED TO BE DISCLOSED UNDER THIS CONTRACT PURSUANT TO THE GOVERNOR’S EXECUTIVE ORDER 98-04. I HAVE ATTACHED TO THIS CHANGE ORDER THOSE DISCLOSURES REQUIRED UNDER THE ORDER. I UNDERSTAND THAT ANY FALSE INFORMATION PROVIDED BY OR OMISSION MADE BY ME MAY BE GROUNDS FOR TERMINATION DUE TO MATERIAL BREACH.

The undersigned entities agree that the following changes shall be incorporated into the contract:

The original contract sum was: $

The net change by previous Change Order was: $

The contract sum prior to this Change Order was: $

The contract sum will be increased /decreased /remain unchanged by this Change Order: $

The new contract sum, which includes this Change Order, shall be: $

The contract time will be increased to/decreased by/remain unchanged: # of days ____________

The date of the contract completion date shall be: ____________________

___________________________________________ ___________________________________________

_______________________________________ ________________________________________

(Address) (Address)

Date: _____________________________________ Date: ______________________________________

THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ARKANSAS ACTING

FOR AND ON BEHALF OF THE UNIVERSITY OF Arkansas (CAMPUS)

BY: ___________________________________________________

VICE PRESIDENT FINANCE & ADMINISTRATION

DATE: _________________________________________________