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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date March 22, 2017 <br />Name Tony Sergio/Roxanne Lawson Department <br />Water Works <br />BPW Date March 28, 2017 Phone Extension 6148 / 5648 <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 />❑ 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 />I-1 Other: <br />Company or Vendor Name N/A <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 Uncollectible Utility Billed Accounts Receivable Write Offs <br />Project Number N/A <br />Funding Source N/A <br />Account No. Multiple accounts in Fund 610 ,620 ,640 ,641, and 655 <br />Amount 2016 - $ 547,007 2015- $ 526,158 <br />Terms of Contract N/A <br />Purpose/Description Reporting uncollectable accounts receivable write offs to comply <br />with the Indiana State Board of Accounts. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc.) <br />Amount of ❑❑ <br />Previous Amount <br />Current Percent of Chanl <br />New Amount <br />Total Percent of Change: % <br />>Dispersal After Approval <br />Copy Original <br />® ❑ Tony Sergio <br />❑ ® Roxanne Lawson <br />❑ 11 <br />