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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />02-21-17 <br />Goben <br />Department SBPD <br />BPW Date 2-28-17 Phone Extension 7520 <br />Required Prior to Submittal to Board <br />Legal ® 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 />U Agreement U Contract U Proposal U Addendum <br />❑ Professional Services ® Resolution (i �Kf1 <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 <br />Yes U No U If Yes, Approved by Purchasing <br />MBE/1NBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Retirement <br />Yes Name of Company _ <br />aift of firearm to Joe Muszer <br />The South Bend Police Dept. requests that the Board of Public Works <br />declare Officer Joe Muszer's Smith & Wesson handgun as surplus <br />his 33yrs of service to the City. Retired: 02-22-17 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc <br />Amount of U 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 />❑ ❑ <br />