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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />10/17/17 <br />Jitin Kain <br />Department Public Works <br />U Agreement <br />LJ Contract <br />U Proposal U Addendum <br />® <br />Professional Services <br />❑ <br />Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />❑ <br />C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease./Encroach. <br />❑ <br />Traffic Control <br />❑ Resolution <br />❑ <br />Other: <br />❑ Claim <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />United W <br />❑ Yes <br />® No <br />❑ MBE <br />❑ WBE <br />AmeriCor <br />rm <br />of St. Joseph County <br />❑ If Yes, Approved by Purchasing <br />Completed E-Verify Form Attached <br />Grant Application <br />222-0616-419-31.06 <br />$10,000 <br />❑ Yes <br />❑ No <br />Grant writinq services to submit the Cit 's application to Serve <br />Indiana for the 2018 AmeriCorps Grant to assist low income <br />families in South Bend with home weatherization services that <br />imorove enerav efficiencv. <br />increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: _ <br />New Amount $ <br />Total Percent of Change: <br />Time Extension: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />Linda Martin <br />Jitin Kain <br />Dispersal After Approval <br />