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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08-16-16 <br />Name Capt. Chris Voros Department Police <br />BPW Date 08-23-16 Phone Extension 7770 <br />Prior to Submittal to <br />Legal ® Attorney Name Michael Schmidt <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑Pro osal <br />❑ Professional Services p ❑Addendum <br />® Resolution <br />❑ Bid Opening ❑ Bid Award <br />El Quote Opening El Quote Award ❑ Req. to Advertise ❑Title Sheet <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/1NBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Retirement gift of firearm to Officer Patricia Byrd for 21 years and <br />Project Name <br />11 months of service. <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />The South Bend Police Department requests the Board of Public <br />Works to declare Officer Patricia Byrd's Smith & Wesson handgun <br />as surplus property and no longer useful to the City of South Bend. <br />Serial # HKB6208. This declaration will authorize the presentation <br />of above listed firearm as a tribute for his 20 plus years of service to <br />the City of South Bend. <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non- <br />('.ollusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Chan e Orders Only <br />Amount of ❑ <br />❑ <br />Increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />Voros <br />1/0 <br />Dispersal After <br />