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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />12-05-16 <br />Sat. Chadwick Goben <br />Department SBPD <br />BPW Date 12-22-16 Phone Extension 7520 <br />Legal (y 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 />❑ Agreement ❑ Contract �❑ Proposal ❑ Addendum <br />❑ Professional Services ® Resolutio4U <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 />I-1 Other: <br />Company or Vendor Name <br />New Vendor ❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name Retirement gift of firearm to Dominic Zultanski <br />Project Number <br />Funding Source <br />Account No. <br />Amount $ <br />Terms of Contract <br />Purpose/Description The South Bend Police Dept. requests that the Board of Public <br />Works declare Officer Dominic Zultanki's Smith & Wesson handgun <br />as surplus property no longer useful to the city. Serial No <br />HKB3617.This declaration will authorize the presentation of the <br />above listed firearm as a tribute for his 20 yrs of service to the City. <br />Retired: 01-2-17 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc.) <br />Amount of H Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: 0/0 <br />New Amount $ <br />Total Percent of Chanqe: °A <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Goben <br />