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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 17, 2016 <br />Name Pam Mever <br />Department Community Investment <br />BPW Date December 13, 2016 Phone Extension 5845 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt, Ben Dougherty <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />® Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Required Information —� <br />Company or Vendor Name Urban Enterprise Association of South Bend, Inc. <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Yes N No ❑ If Yes, Approved by Purchasing <br />MBE ❑ WBE <br />UEA Staff <br />Fund 211 <br />$ 45,000 paid to <br />January 1, 2017- December 31, 2017 <br />Payment for staff serices through DCI for the administration of the <br />Enterprise Associaiton of SOuth Bend, Inc. activities and programs <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc. <br />uired For Change Orders <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 />® ® Pam Meyer, DCI <br />® ❑ Ben Dougherty, Legal <br />❑ ❑ <br />Urban <br />