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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 7/26/2019 <br />Name <br />Lory Timmer <br />Department DCI <br />��,r��B W Date: v.�8/13/ <br />2019 <br />.... _ <br />Phone Extension <br />o <br />-m, ... �.._.... . <br />5841 <br />...... ... Sub �.� Board <br />�._ ._.... _� ._._........, m uired Prior to mittal to w_. ... .. _....._ .. <br />BPW Attorney ^^ ® Attorney <br />'els <br />Name Clara McDani ......� <br />Dept. Attorney ® Attorney Name Sandra Kenned <br />Purchasing ® Michael Schmidt <br />P Checkthe A jrgp, t mItem [ y � <br />rofessional Services Agreement Contract <br />Open Market Contract ❑ Amendment/Addendum <br />❑ Bid Opening Bid Award <br />❑l Quote Opening EJ Quote Award <br />❑ Proposal Opening El C/O & PCA No. <br />Other: Chg. Order No ffi Trac Control <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />M <br />Information <br />All Submissions <br />L, Proposal <br />Special Purchase, QPA <br />Req. to Advertise <br />Reject Bids/Quotes <br />E] PCA <br />E] Resolution <br />❑ Ease./Encroach <br />❑ Title Sheel <br />South Bend Human I its Commission <br />. ®Nos .....___..... .......rr�._.._... ......... ___. �. .....�. <br />❑ If Yes, Approved by Purchasing <br />❑ MBE Completed E-Verify Form Attached Z Yes <br />❑ WBE ❑ No <br />..... ............ es <br />Affirmative Fair Housin Activities....................�..._......._.... ._,,...... <br />19-JC-89 <br />m. � .....w -- <br />....... .. <br />v p CDBG <br />Commumt Develo ment Block Grant ( m ) ... y <br />212.1001.460.39.30 <br />$10....� ----- _- .,... ... <br />,000.00... <br />$1 ......� <br />1/01/2019 — 12/31/2019 <br />Subsidize the cost of mvestig l t is ng disc.rinji,I atiop cornppa <br />pygyidiRg fir Ic J si g iucation <br />For .CI c .. �. <br />Orders„�1.......... _...... <br />Amount of ❑ increase $ <br />❑ Decrease �$ ) <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />El <br />Increase <br />Decrease /o <br />Increase % <br />Total Percent of Change: Decrease ° <br />g <br />Time Extension Amount: <br />New Completion Date: �_�_...�........._.m,.m...................._...........u.._.�,... <br />