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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />'16 <br />Timmer <br />Department DCI <br />BPW Date 9/13/16 Phone Extension 5841 <br />Required Prior to Submittal to Board <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 ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: Amendment <br />Information <br />Company or Vendor Name <br />South Bend Human Rights Commission <br />New Vendor <br />❑ Yes ® <br />No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ <br />WBE <br />MBE/WBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name <br />Affirmative Fair Housing Activities <br />Project Number <br />16-JC-89 <br />Funding Source <br />Community Development Block Grant (CDBG) <br />Account No. <br />212.1001.460.39.30 <br />Amount $10,000 <br />Terms of Contract 1/01116 — 12/31/16 <br />Purpose/Description Increase agency's capacity to investigate housing discrimination <br />complaints and provide fair housing education <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion Non -Discrimination Non -Debarment E-Verify,Iran etc ) <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Judy Love <br />❑ ❑ <br />❑ 0 <br />