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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />March 18„, 2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date March 26, 2018 <br />'IHIVdVdVWG'6HiiYW h"i4iV'PIdk451'1W'NW.?fw';'4d"U 'agvwW W <br />Phone Extension 574-235-9316 <br />III AYID�d `Yfl4fPJiIR' ':11@'WN'fRMIF/�N WmmIMINI a iJu1C2�butd'£ "'.�, ten, .. IFi'!M <br />m...... <br />m ,.,. .�N .6'Pn"gHMIIIIIIIIMOMOMS <br />Re.... gired Prior to Submittal to Board <br />Legal ® <br />Attorney Name Clara McDaniels <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® <br />Michael Schmidt <br />_.. Check the A ro nate Item Type 7_! egguire�orr All Submissions <br />P❑ <br />❑ Agreement <br />. <br />Contract Proposal El Addendum dum <br />Professional Services <br />❑ Resolution <br />0 Bid Opening <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />F] Quote Opening <br />❑ Quote Award <br />Ej Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />F ] Ease/Encroach. <br />❑ Traffic Control <br />�] Other: <br />� .. . _...m9„ _.,,_9. ...................... <br />q ...— .................. 6 <br />R uired Information <br />Company or Vendor Name <br />New Vendor <br />❑ <br />_❑ <br />Yes <br />No El If Yes, Approved by Purcha <br />mmmmm WWWWWWW sink <br />MBE/WBE Contractor <br />MBE WBE <br />❑ <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />_ <br />Spec H — Seventeen (17) more or less 2019orNewer Mid -Size Four <br />Project Name <br />Door H brid Sedan Automob <br />y Automobiles <br />Project Number <br />.................. ..._....._..... <br />2019 Police Department Lease & Principal Budget <br />Funding Source <br />2019 Water WorksCapital Budget & 2019 _Fimra Dept. mmCapital �Budget <br />IT...... <br />(PD Lease) 101-0801-421-38-01 (PD Interest) 101-0801-421-38-02 <br />Account No. <br />(Water) 622-0640-415-43-02mm��Fire�7-090 <br />ww m_w 282-422-43-02 <br />.........�................................ <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Bid Opening Date: April 23, 2019 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion„ Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc. <br />Amount of Increase `$ <br />�] Decrease $ <br />Previous Amount mmm$ <br />Current Percent of Change: <br />New Amount $ <br />......................... <br />Total Percent of Change: <br />%.............. ........... <br />_.. <br />Dispersal After Approval <br />Copy Original <br />® E] Jeff Hudak <br />® m .L.an......_... _.... <br />Renata Matousova, Ti _caster <br />® ❑ Todd Skwarcan, Roxanne Lawson & Al Green <br />