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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />10/06/16 <br />Timmer <br />Department DCI <br />BPW Date 10/25/16 Phone Extension 5841 <br />I 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 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 />n <br />Other: <br />Company or Vendor Name <br />Oaklawn Psychiatric Center Inc. <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEM/BE Contractor <br />❑ MBE ❑ WBE <br />MBEM/BE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name <br />Shelter +Care - Oaklawn <br />Project Number <br />16-JS-06 <br />Funding Source <br />Continuum of Care Program Grant (CoC) <br />Account No. <br />212.1001.460.39.30 <br />Amount <br />$278,076 <br />Terms of Contract <br />9/01/16 — 8/31/17 <br />Purpose/Description <br />Provide rental assistance to eligible Oaklawn clients <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 />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />U�0 <br />Love <br />Dispersal After Approval <br />