Laserfiche WebLink
BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/01/2019 <br />Department Human <br />Name Tierra Davis Resources <br />BPW Date 11/12/19 Phone Extension 5510 <br />u w �..... .., xmm :.n�, :,,r�^ r�sv�wxmnxe rv�w� ffmf .yumv mimuuuwti mommi� <br />.. .�.,...�.�.-.. �._._�._.. Re, <br />quired Prior to Submittal to Bo.. <br />and <br />BPW Attorney ® Attorney Name <br />Dept. Attorney, Attorney Name Danielle Weiss <br />Purchasing El <br />Check the Appropriate Item Type _. <br />Professional Services Agreement ® Contract <br />El Open Market Contract <br />El Amendment/Addendum <br />Bid Opening <br />❑ Bid Award <br />Quote Opening <br />E] Quote Award <br />❑ Proposal Opening <br />❑ C/O & PCA No, <br />E] Chg. Order, No. <br />❑ Traffic Control <br />EJ Other: <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 />Information <br />All Submissions <br />Proposal <br />LJ Special Purchase, QPA <br />Req. to Advertise <br />Reject Bids/Quotes <br />PCA <br />Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />Accordware LLC <br />Yes El If Yes, Approved by Purchasing <br />® No <br />❑ MBE Completed E-Verify Form Attached El Yes <br />❑ WBE ❑ No <br />ACA-R�.. __�._........rn 1095-C <br />e ortm or IRS Forms 1094-C & <br />Health Insu <br />rance Fund <br />711-0401-671-31-06 <br />$1.40 per 1095-C Form and $1.00 per employee reporting fee; there is a <br />$1 „000 Annual Base Fee <br />Terms of Contract The agreement covers the reporting e �od for themm2019 calendar year, w <br />Purpose/Description Accordware LLC will assist with fulfillment of the Cit 's re orting <br />obligations ursuant to the Patient Protection and Affordable Care Act to <br />sates 1..0...9.4 & 1095 rMqr.in._.g requirements wit_h....r._.e and to the IRS_ .,.... <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount $ <br />Increase� %... .....�_ � ....m...�.�-......................._�........__ <br />Current Percent of Change: Decrease %) <br />New Amount $ <br />Increase.....................m.........._..........%...�........_......�....e.. ..— m......�.�.�.�...�..�aa_. <br />�� ... ..... �a. <br />Total Percent of Change: Decrease %) <br />Time Extension Amount: <br />New Completion Date: <br />