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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 5/23/2023 <br />Name Scott Kreeger Department PW <br />BPW Date 6/13/23 Phone Extension 9245 <br /> <br />Required Prior to Submittal to Board BPW Attorney Attorney Name Michael Schmidt <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 <br />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: Ease./Encroach <br />Required Information <br />Company or Vendor Name Indiana Department of Transportation <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 Locust Road Improvements from Assumption Drive to State Road 23 <br />Project Number 123-018 <br />Funding Source Fund 265 <br />Account No. MVH-R, Local Roads & Bridges <br />Amount 266-06-602-503-436008, 265-06-600-506-436008 <br />Terms of Contract <br />Purpose/Description The Community Crossings Matching Grant (CCMG) 50/50 cost share up to <br />$1,000,000 for the road rehabilitation of various City streets. <br />__________________________ <br />For Change Orders Only <br />Amount of <br /> <br />Increase <br />Decrease <br />$ <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 /> Time Extension Amount: <br />New Completion Date: <br /> <br />