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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 N 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 />H Agreement LJ Contract \�Q U Proposal LJ Addendum <br />❑ Professional Services ® Resolution-*�J- <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 />f-1 Other: <br />Company or Vendor Name <br />New Vendor ❑ Yes ❑ No [ <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBEM/BE Contractor Requested ❑ No ❑ <br />Project Name Retirement <br />Project Number <br />If Yes, Approved by Purchasing <br />Yes Name of C <br />gift of firearm to <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 Robert Hammer's Smith & Wesson handgun <br />as surplus property no longer useful to the city. Serial No <br />HKB5067.This declaration will authorize the presentation of the <br />above listed firearm as a tribute for his 24 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-Verify, Iran, etc. <br />;:; = RegUifed for=Gf tr�ge Ord6 C?n'ly, <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 />® ❑ Sgt. Goben <br />❑ ❑ <br />0 ❑ <br />