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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 2/25/22 <br />Name Kim Thompson <br />Department Public <br />Works <br />BPW Date 3/8/22 Phone Extension 5969 <br /> <br />Review and Approval Required Prior to Submittal to Board Diversity Compliance <br />and Inclusion Officer Officer Name BPW Attorney Attorney Name <br />Dept. Attorney Attorney Name <br /> <br />Purchasing <br />Check the Appropriate Item Type – Required for All Submissions <br /> Professional Services Agreement Contract Proposal <br /> Open Market Contract Amendment/Addendum Special Purchase, QPA <br /> Bid Opening Bid Award Req. to Advertise Title Sheet <br /> Quote Opening Quote Award Reject Bids/Quotes <br /> Proposal Opening C/O & PCA No. PCA <br /> Chg. Order, No. Traffic Control Resolution <br /> Other: Utility Relief <br /> Ease./Encroach <br />Required Information <br />Company or Vendor Name N/A <br />New Vendor Yes If Yes, Approved by Purchasing <br /> No <br />MBE/WBE Contractor MBE <br /> WBE Completed E-Verify Form Attached Yes <br /> No <br />Project Name City of South Bend Utility Relief 2022 <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description ____BPW resolution to forgive past due balances on residential utility <br />accounts. <br />_______________________________________________________________ <br />_______________________________________________________________ <br />_______________________________________________ <br />For Change Orders Only <br />Amount of <br /> <br />Increase <br />Decrease <br />$ <br />($ ) <br />Previous Amount $ <br />Current Percent of Change: <br />Increase <br />Decrease <br /> % <br />( %) <br /> New Amount $ <br />Total Percent of Change: <br />Increase <br />Decrease <br /> % <br />( %) <br />