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<br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br /> <br />Date 1/14/24 <br />Name Michael Schmidt Department Legal <br />BPW Date 1/28/25 Phone Extension <br /> <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />and Inclusion Officer Officer Name <br />BPW Attorney Attorney Name Michael Schmidt <br />Dept. Attorney Attorney Name Kylie Connell <br />Purchasing <br /> <br /> <br /> <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: Lease Ease./Encroach <br />Required Information <br />Company or Vendor Name Fraternal Order of Police Lodge 36 <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 /> <br />Project Name <br />License Agreement - Use of Property Located at 23527 State Road <br /> 23, South Bend, Indiana <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract 3 Year Lease, $47,500, $55,000, and $62,500 <br />Purpose/Description <br />For Change Orders Only <br />Amount of Increase <br />Decrease <br /> $ <br />($ ) <br />Previous Amount $ <br /> <br />Current Percent of Change: <br />Increase % <br />Decrease ( %) <br /> <br />New Amount $ <br /> <br />Total Percent of Change: <br />Increase % <br />Decrease ( %) <br /> <br />Time Extension Amount: <br />New Completion Date: <br />