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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />08-31-16 <br />Voros <br />Department SBPD <br />BPW Date 09-13-16 Phone Extension 7770 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />® Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />7 <br />Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBEM/BE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Retirement gift of firearm to Amy Bennett <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />The South Bend Police Dept. requests that the Board of Public <br />Works declare Officer Amy Bennett's Smith & Wesson handgun as <br />surplus property no longer useful to the city. Serial No <br />HKB3654.This declaration will authorize the presentation of the <br />above listed firearm as a tribute for his 21 yrs of service to the City. <br />Retired: 09-12-16 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Chan a Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Lt. Voros <br />❑ ❑ <br />❑ ❑ <br />