HomeMy WebLinkAboutAgreement - Goodwill Industries of Michiana - Bridger Merger with Goodwill1316 COUNTY -CITY BUILDING
227 w.JEFFERSON BOULEVARD
901JTH BEND. INDIANA 46601-1930
CITY OF • BEND PETE BUTTIGIEG, MAYOR
BOARD ' 1 OF PUBLICWORKS
December 20, 2018
Debie Cole
Goodwill Industries of Michiana, Inc.
1805 W. Western Avenue
South Bend, IN 46619
RE: Agreement
Dear Ms. Cole:
PHONE 574/235-9251
FAx 574/235-9171
The Board of Public Works, at its meeting held on December 20, 2018, approved the above
referenced agreement to revise the employer resource navigator contracting organization
due to Bridges Merger with Goodwill, and extend the agreement through 2019 for balance
of funds in the amount of $17,916.
Enclosed please find a copy of the agreement for your records.
If you have any further questions regarding this matter, please call this office at (574) 235-
9251.
Sincerely,
Linda" M. Martin, Clerk
Enclosure
GARY A. GILOT SUZANNA M. FRrrzBERG ELIZABETH A. ARADII( JAMES A. MUELLER THERESE J. DoRAu
AGREEMENT FOR PROGRAMS AND SERVICES
THIS AGREEMENT (the or this "Agreement") is made effective the 20th day of
December, 2018, by and between the CITY OF SOUTH BEND, INDIANA, a municipal
corporation organized and operating under the laws of the State of Indiana, acting by and
through its Board of Public Works (the "City"), and GOODWILL INDUSTRIES OF
MICHIANA, INC., an Indiana non-profit corporation with an address of 1805 W. Western
Avenue, South Bend, Indiana 46619 (the "Organization").
RECITALS
WHEREAS, the Organization is an innovative organization whose mission is to
enhance the dignity and quality of life of individuals and families by strengthening
communities, eliminating barriers to opportunity, and helping people in need reach their
full potential through learning and the power of work; and
WHEREAS, the Organization provides the Bridges Initiative at Goodwill
program, which includes an Employer Resource Network ("ERN"), designed to provide
assistance for low-income, entry level workers not only to keep jobs, but to build the
stability that will lead to self-sufficiency, while simultaneously reducing employee
turnover and absenteeism, as more particularly described at Exhibit A (the "Program");
and
WHEREAS, the Organization is duly qualified to provide for, oversee, and
administer the Program; and
WHEREAS, the City desires to assist local employers in providing the Program;
and
WHEREAS, the City believes that the actions contemplated by this Agreement are
in the best interests of the health, safety, and welfare of the City and its residents and that
such actions comply with the public purposes and applicable provisions of state and local
law.
NOW THEREFORE, for and in consideration of the mutual covenants and
promises contained herein, the City and the Organization hereby agree as follows:
1. Contract Amount and Term. The Organization shall provide the programs
and services set forth at Exhibit A to employers and their employees located in the City for
the period commencing January 1, 2019 and ending December 31, 2019 (the "Program
Term"). In accordance with the terms and conditions of this Agreement, the City will
expend an amount not to exceed Seventeen Thousand Nine Hundred Sixteen Dollars
($17,916.00) for the Organization's services during the Program Term.
2. Pi g wn Bigl c I. The Organization shall not seek from the City more than
the Contract Amount for any expenses related to the Program or otherwise.
1
3. CompensalLon lin' il-o Latn. The City will pay the Contract Amount in
accordance with this Section 3. The Organization will use each installment of the Contract
Amount for the sole and limited purpose of defraying the costs of employing one (1) full-
time ERN specialist responsible for providing the Program to employers and their
employees in the City. The City will not pay any portion of the Contract Amount to the
Organization unless the Organization first obtains a payment from an employer in the City
that desires to participate in the Program, the amount of which payment will be in
increments of Four Thousand Dollars ($4,000.00) (an "Employer Payment"). After
receiving an Employer Payment, the Organization will submit a written notice to the City
stating the name of the employer and the amount of the Employer Payment that the
Organization desires for the City to match, the City will pay to the Organization an amount
equal to the Employer Payment described in the Organization's written notice (the
"Contract Installment"), provided, however, that the City will not be required to pay any
Contract Installment if the City is not satisfied with the Organization's performance under
this Agreement or any default or breach of this Agreement by the Organization exists, as
the City may determine in its sole discretion. The sum of all Contract Installments will not
exceed the Contract Amount. The City will not pay a Contract Installment for any
Employer Payment received by the Organization after September 30, 2019.
4. L)e.� jgn and brr lementation cj' Pi co r°arn ° g or•tiw. To the extent not set
forth in Exhibit A, the Organization shall be solely responsible for the design and
implementation of the Program, unless specifically directed otherwise by the City's
Director of Neighborhood Engagement (the "Contract Administrator"). The Program and
this Agreement must be performed and administered in accordance with all applicable
federal, state, and local laws. During the Program Term, the Organization will submit
quarterly reports on or near the dates of April 1, July 1, October 1, and December 31, 2019,
setting forth detailed records showing the ERN specialist's time spent and services
performed at the site of each employer after the employer has made an Employer Payment
and begun participating in the Program.
5. Termination of A ueement. Effective immediately upon delivery of a
written termination notice to the Organization, the City may terminate this Agreement, in
whole or in part, for any reason, if the City determines that such termination is in the best
interest of the City. Further, if the City Controller makes a written determination that funds
are not appropriated or are otherwise unavailable to support the continuation of this
Agreement, it shall be cancelled. A determination by the City Controller that funds are not
appropriated or are otherwise unavailable to support the continuation of performance shall
be final and conclusive. The City will not be required to pay any Contract Installment or
be otherwise liable for any cost associated with the ERN specialist after the effective date
of termination. In no case shall total payment made to the Organization exceed the original
Contract Amount.
6 Rernedies n- Breach rah` (ontrac°t. Failure to complete the Program in
accordance with this Agreement may be considered a material breach, and shall entitle the
City to impose sanctions against the Organization including, but not limited to, suspension
2
of all payments, and/or suspension of the Organization's involvement in the Program, on
behalf of the City. The Organization shall repay any portion of the Contract Amount
expended for matters not within the scope of the Program or the Budget.
7. Maintenance err 'RecorMt Acces-s to I ecor•ch. The Organization shall keep
a written record, in a form acceptable to the City, related to the use and expenditure of the
Contract Amount. Within thirty (30) days of the expiration or termination of this
Agreement, the Organization shall provide the City with a final accounting of the use and
disposition of the Contract Amount by the Organization. Unless otherwise authorized by
the City or required by law, such records shall be maintained by the Organization for a
period of four (4) years of the date of this Agreement. The Organization understands and
agrees to comply with the legal requirements of I.C. Sec. 5-14-3-1 et seq. (commonly
known as Indiana's Access to Public Records Act), if applicable, with respect to all
documentation related to the Contract Amount.
8.The Organization agrees to make all information
available to the Indiana State Board of Accounts, the City's Internal Auditor, and the
Contract Administrator as requested to comply with any audit requested related to the
receipt and use of the Contract Amount and the Organization's performance in delivering
the Program in accordance with the provisions of this Agreement. If requested by the City
or the Contract Administrator, the Organization shall provide the City a progress report on
the Program. If requested by the City or the City's Internal Auditor, the Organization shall
arrange for a financial and compliance audit of the Contract Amount to be conducted by
an independent public or certified public accountant (or as applicable, the Indiana State
Board of Accounts) and in accordance with applicable Indiana State Board of Accounts
standards. The City's Internal Auditor shall mean the City Controller or Acting City
Controller appointed pursuant to I.C. Sec. 36-4-9-6 (the "City Controller") or any person
appointed or retained by the City Controller or the City for the purpose of auditing the
Organization for this Agreement or other agreements of the City.
9. C.."onflrets of Interest. The Organization hereby certifies and agrees that no
member, officer, or employee of the City, or its designees or agents, and no member of the
governing body of the City or the Organization (and no one with whom there is a family
or business tie) who exercises any functions or responsibilities with respect to the receipt
and use of City funds during his or her tenure or for one year thereafter, shall have any
financial benefit, direct or indirect, in any contract or subcontract, or the proceeds thereof,
for work to be performed in connection with the Program. The City acknowledges that its
officers and employees are "public servants" within the meaning of I.C. Sec. 35-31.5-2-
261. The City hereby represents and certifies that it may enter into this Agreement under
I.C. Sec. 35-44.1-1 et seq. and, to the extent applicable, the City will cause to be prepared
any required Uniform Conflict of Interest Disclosure Statement in the form attached hereto
as Exhibit B.
10. Relationship. The Organization shall at all times be an independent
contractor for the performance of the Program rather than an employee of the City, and no
act, action or omission to act by the Organization shall in any way bind or obligate the City.
3
This Agreement is strictly for the benefit of the parties and not for any third -party or person.
This Agreement was negotiated by the parties at arm's length and each of the parties hereto
has reviewed the Agreement after the opportunity to consult with independent legal
counsel. Neither party shall maintain that the language in the Agreement shall be construed
against any signatory hereto. The City and the Organization hereby renounce the existence
of any form of agency relationship, joint venture or partnership between the Organization
and the City and agree that nothing contained herein or in any document executed in
connection herewith shall be construed as creating any such relationship between the City
and the Organization.
11. Incleinnific:aation. The Organization hereby agrees to defend, indemnify, and
hold harmless the City, its officials, employees, and agents from any and all claims of any
nature which arise from the performance by the Organization under this Agreement and
from all costs and attorney fees in connection therewith, excepting for claims arising out
of the negligence of the City, its officials, directors, employees, and agents. The
obligations of the Organization under this Section shall survive the termination of this
Agreement.
12. NotictcS. Any notice required or permitted to be delivered hereunder shall
be deemed to be delivered, whether or not actually received, when deposited in the United
States Postal Service, postage prepaid, registered or certified mail, return receipt requested,
addressed to the City or the Organization, as the case may be, at the address set forth below.
— I ization:
LeRoy C. King, III, Director
Bridges Initiative at Goodwill
Goodwill Industries of Michiana, Inc.
P.O. Box 3846
South Bend, IN 46619
City
Pamela C. Meyer, Director
Neighborhood Engagement
City of South Bend, Indiana
227 W. Jefferson Boulevard, 1400S
South Bend, IN 46601-1830
13. L,jeyal Ctaarai" . The Organization shall comply with federal, state, and
local law in its hiring and employment practices and policies for any activity covered by
this Agreement.
14. Entire rlir�ew c11761.4niendin w • AtjnW is able Lmv. This Agreement sets
forth the entire agreement and understanding between the parties as to the subject matter
hereof, and merges and supersedes all prior discussions, agreements, and understanding of
any and every nature between them. This Agreement may be amended only by separate
writing, approved by both the Organization and the City. This Agreement will be construed
and interpreted according to the laws of the State of Indiana.
15. J vs s�r�� nl. The Organization shall not assign or subcontract the whole or
any part of this Agreement or its obligations hereunder without the prior written consent
of the City.
16. .4ciclitir: nal R'.eLyeseniglions. The undersigned persons executing and
delivering this Agreement on behalf of the Organization represent and certify that they are
L
the duly authorized officers of the Organization and have been fully empowered to execute
and deliver this Agreement and that all necessary corporate action has been taken and done.
17. Corr- rrllt.icrra. The undersigned attests, subject to the penalties of perjury,
that he/she is the properly authorized representative, agent, member or officer of the
Organization and that he/she has not, nor has any other member, employee, representative,
agent or officer of the Organization, directly or indirectly, to the best of his/her knowledge,
entered into or offered to enter into any combination, collusion or agreement to receive or
pay, and that he/she has not received or paid any sum of money or other consideration for
the execution of this Agreement other than that which appears upon the face hereof. The
Organization agrees that it will execute and submit to the City and any other appropriate
bodies, an affidavit in the form attached hereto as Exhibit C.
18. Dr°rr -b`ree Work-
place. The Provider hereby agrees to make a good faith
effort to provide and maintain a drug -free workplace. The Provider will give written notice
to the City within ten (10) days after receiving actual notice that the Provider or an
employee of the Provider within the State of Indiana has been convicted of a criminal drug
violation occurring in the workplace.
19. '- VeYri . The Organization hereby certifies that it does not and will not
knowingly employ or contract with an unauthorized alien, nor retain any employee or contract
with a person that the Organization subsequently learns is an unauthorized alien. The
Organization agrees that he/she/it shall enroll in and verify the work eligibility status of all of
the Organization's newly hired employees through the E-Verify Program as defined by I.C.
Sec. 22-5-1.7-3.
(Signature page follows)
E
IN WITNESS WHEREOF, the Parties hereto have entered into this Agreement
to be effective as of the day and year first above written.
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
'a . . . . ..................... . .....
Gary A. Gil.ot, President
T1ierese Dorau, �P enibei-
a iia .°g; en,,/
Elizabeth Mratij, Member
_....
.lees-in�m Member ..._ ........................
ATTEST
l.shda. M. Martin
GOODWILL INDUSTRIES OF
MICHIANA, INC.
Y_ ....._.__
Signature
Debie Coble President/Ceo
Printed Nance and Title _._..............
G
EXHIBIT A
Program Description
The Bridges Initiative at Goodwill Employer Resource Network ("ERN") is based on new
strategies that can solve employee problems to the best of our ability. The ERN helps under-
resourced employees keep their job; streamlines the process of connecting an individual to the
community or government resources he or she needs but may not otherwise access; and reduces
employees' stress which increases productivity and overall job performance.
In accordance with the above statement and during the Program Term, the Organization shall
provide the following services and programs:
Provide a skilled Resource Navigator who will focus on connecting employees
with community resources or new strategies that can help solve any problem,
eliminating or decreasing the need for that employee's time away from work.
2. Provide a Resource Navigator who is able to meet employees at the worksite,
during breaks and shift changes, or on the phone, making access as simple and
flexible as possible for the employee.
3. Conduct employer education through trainings on the principles, goals, and
procedures of the ERN to create a general understanding and improve utilization
of the program.
4, Provide quantitative data to the employer and the City to include but not be
limited to:
• Hours and service provided per business and in aggregate
• Number of Employees assisted per business and in aggregate
• Number of issues addressed per business and in aggregate
• Turnover rate for served employees versus total population of entry level
employees per business based on provision of necessary data from
employer
EXHIBIT B
Uniform Conflict of Interest Disclosure Statement
[See attached.]
BUSINESS INFORMATION
CONNIE LAWSON
INDIANA SECRETARY OF STATE
E
12/12/2018 11:28 AM
MINIM
Business Name: GOODWILL INDUSTRIES OF Business ID: 194368-050
N1101 ]ANA, INC.
Entity Type: Domestic Nonprofit Corporation Business Status: Active
Creation Date: 02/13/1963 Inactive Date:
Principal Office Address:
1805 WESTERN AVE, PO BOX 3846, Expiration Date: Perpetual
SOUTH BEND, IN, 46619 - 4661, USA
Jurisdiction of Formation:
Indiana
Business Entity Report Due 02/28/2019
Date:
Years Due: 2019/2020
Title
Name
Address
Director
John W. Elliott
3051 East Liverpool Road, Winona Lake, IN, 46590 - 8901, USA
Chairman
Tracee A. Siade-Jones
Memorial Hospital, 100 E Wayne Streer, South Bend, IN, 46601, USA
LEADS Board Liaison
Anthony Allison
330 E. Jefferson Blvd, South Bend, IN, 46624 - 0007, USA
Vice Chair
Sharon V. Hawkins
Univ of ND, 100 Grace Hall, Notre Dame, IN, 46556, USA
Director
William Veldman
57769 Crumstown Hwy, South Bend, IN, 46619, USA
Treasurer
Thomas Kuhar
25678 Rolling Hills Drive, South Bend, IN, 46628, USA
Secretary
Richard Hill
16327 Cypress Court, Granger, IN, 46530, USA
President
Debie M. Coble
1805 WESTERN AVE, SOUTH BEND, IN, 46619 - 4661, USA
Director
Jacqueline M. Barton
1001 E. Jefferson Blvd, South Bend, IN, 46617, USA
Director
Cynthia Kilgore
17171 Arthur Street, Granger, IN, 46530, USA
Director
Jessica Lambert
1338 Breezy Beach, Niles, MI, 49120, USA
LEADS Board Liaison
Rolla Baumgartner
350 Carefree Court, Niles, MI, 49120, USA
Director
Michelle Peters
215 W. 4th Street, Mishawaka, IN, 46544, USA
Director
Perry Watson 111
4325 Grape Road, Mishawaka, IN, 46545, USA
Type: Individual
Name: DEBIE M COBLE
Address: 1805 WESTERN AVE, SOUTH BEND, IN, 46619 - 4661, USA
IRScc Department of the "I°rutwuaw V
Internal Revenue svr't"Icn^
P.O. Box 2508
Cincinnati OH 45201
GOODWILL INDUSTRIES OF MICHIANA INC
1805 W WESTERN AVE
SOUTH BEND IN 46619
In reply refer to: 0248164843
Feb. 13, 2018 LTR 4168C 0
35-1093073 000000 00
00009765
BODC: TE
051042 +
Employer ID Number: 35-1093073
Form 990 required: Yes
Dear Taxpayer:
This is in response to your request dated Feb. 02, 2018, regarding
your tax-exempt status.
We issued you a determination letter in July 1938, recognizing
you as tax-exempt under Internal Revenue Code (IRC) Section 501(c)
(3).
Our records also indicate you're not a private foundation as defined
under IRC Section 509(a) because you're described in IRC Section
509(a)(2).
Donors can deduct contributions they make to you as provided in IRC
Section 170. You're also qualified to receive tax deductible bequests,
legacies, devises, transfers, or gifts under IRC Sections 2055, 2106,
and 2522.
In the heading of this letter, we indicated whether you must file an
annual information return. If a return is required, you must file Form
990, 990-EZ, 990-N, or 990-PF by the 15th day of the fifth month after
the end of your annual accounting period. IRC Section 6033(j) provides
that, if you don't file a required annual information return or notice
for three consecutive years, your exempt status will be automatically
revoked on the filing due date of the third required return or notice.
For tax -forms, instructions, and publications, visit www.irs.gov or
call 1-800-TAX-FORM (1-800-829-3676).
If you have questions, call 1-877-829-5500 between 8 a.m. and 5 p.m.,
local time, Monday through Friday (Alaska and Hawaii follow Pacific
Time).
EXHIBIT C
Contractor's Affidavit
[See attached.]
When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affidavit.
CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION REGARDING
INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT
AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
STATE OF
(Must be completed for all quotes and bids. Please type or print)
) SS:
COUNTY )
The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury that:
1. Contractor has not, nor has any other member, representative, or agent of the firm, company,
corporation or partnership represented by him, entered into any combination, collusion or agreement
with any person relative to the price to be bid by anyone at such letting nor to prevent any person from
bidding nor to induce anyone to refrain from bidding, and that this bid is made without reference to any
other bid and without any agreement, understanding or combination with any other person in
reference to such bidding. Contractor further says that no person or persons, firms, or corporation has,
have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account
of such sale; and
2. Contractor certifies by submission of this proposal that neither contractor nor any of its
principals are presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any Federal department or agency; and
3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
investment activities in Iran.
a. For purposes of this Certification, "Iran" means the government of Iran and any agency or
instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended
from time -to -time.
b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is
engaged in investment activities in Iran if either:
L Contractor, its successor or its affiliate, provides goods or services of twenty million
dollars ($20,000,000) or more in value in the energy sector of Iran; or
ii. Contractor, its successor or its affiliate, is a financial institution that extends twenty
million dollars ($20,000,000) or more in credit to another person for forty-five (45)
days or more, if that person will (i) use the credit to provides goods and services in
the energy sector in Iran; and (ii) at the time the financial institution extends credit,
is a person identified on list published by the Indiana Department of Administration,
Non -Collusion Non -Debarment Affidavit Non Iran Form 2016
4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain any
employee or contract with a person that the Contractor subsequently learns is an unauthorized alien.
Contractor agrees that he/she/it shall enroll in and verify the work eligibility status of all of Contractor's
newly hired employees through the E-Verify Program as defined by I.C. 22-5-1.7-3. Contractor's
documentation of enrollment and participation in the E-Verify Program is included and attached as part
of this bid/quote; and
5. Contractor shall require his/her/its subcontractors performing work under this public contract
to certify that the subcontractors do not knowingly employ or contract with an unauthorized alien, nor
retain any employee or contract with a person that the subcontractor subsequently learns is an
unauthorized alien, and that the subcontractor has enrolled in and is participating in the E-Verify
Program. The Contractor agrees to maintain this certification throughout the term of the contract with
the City of South Bend, and understands that the City may terminate the contract for default if the
Contractor fails to cure a breach of this provision no later than thirty (30) days after being notified by
the City.
6. Persons, partnerships, corporations, associations, or joint venturers awarded a contract by the
City of South Bend through its agencies, boards, or commissions shall not discriminate against any
employee or applicant for employment in the performance of a City contract with respect to hire,
tenure, terms, conditions, or privileges of employment, or any matter directly or indirectly related to
employment because of race, sex, religion, color, national origin, ancestry, age, gender expression,
gender identity, sexual orientation or disability that does not affect that person's ability to perform the
work.
In awarding contracts for the purchase of work, labor, services, supplies, equipment, materials, or any
combination of the foregoing including, but not limited to, public works contracts awarded under public
bidding laws or other contracts in which public bids are not required by law, the City, its agencies,
boards, or commissions may consider the Contractor's good faith efforts to obtain participation by
those Contractors certified by the State of Indiana as a Minority Business ("MBE") or as a Women's
Business Enterprise ("WBE") as a factor in determining the lowest, responsible, responsive bidder.
In no event shall persons or entities seeking the award of a City contract be required to award a
subcontract to an MBE/WBE; however, it may not unlawfully discriminate against said WBE/MBE. A
finding of a discriminatory practice by the City's MBE/WBE Utilization Board shall prohibit that person or
entity from being awarded a City contract for a period of one (1) year from the date of such
determination, and such determination may also be grounds for terminating the contact for which the
discriminatory practice or noncompliance pertains.
7. The undersigned contractor agrees that the following nondiscrimination commitment shall be
made a part of any contract which it may henceforth enter into with the City of South Bend, Indiana or
any of its agencies, boards or commissions.
Contractor agrees not to discriminate against or intimidate any employee or applicant for employment
in the performance of this contract with privileges of employment, or any matter directly or indirectly
related to employment, because of race, religion, color, sex, gender expression, gender identity, sexual
Non -Collusion Non -Debarment Affidavit Non Iran Form 2016
orientation, handicap, national origin or ancestry. Breach of this provision may be regarded as material
breach of contract.
I, the undersigned bidder or agent as contractor on a public works project, understand my statutory
obligations to the use of steel products or foundry products made in the United States (I.C. 5-16-8-1). 1
hereby certify that I and all subcontractors employed by me for this project will use steel products or
foundry products made in the United States on this project if awarded. I understand I have an
affirmative duty to notify the City in my bid that my proposal does not include the use of steel products
or foundry products made in the United States. I understand it is my sole obligation and responsibility to
provide a justification to the City, subject to review and approval, why the cost of United States made
steel or foundry products is unreasonable. Prior to award and upon submission of bid which does not
use steel products or foundry products made in the United States, the City, through its director of public
works, shall make a determination if the price of United States made steel or foundry is unreasonable. I
understand that violations hereunder may result in forfeiture of contractual payments.
I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid for
public works are true and correct.
Dated this day ofLF2LnfiIL A 0/0
Contractor/Bidder (Firm)
Signature of Contra(ttor/&idder or Its Agent
Printed Name and Title
..� r
Subscribed and sworn to before me this day of 0
MYCDM�ja
.
Notary Putilic Stete-of Indiana Notary Public
St. Joseph Counter
My Eqir dab"l, 7Ao Residence
Non -Collusion Non -Debarment Affidavit Non Iran Form 2016
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date December 18, 2018
Name Pam Meyer Department DCI
BPW Date December 20, 2018 Phone Extension 5845
Warn w�rcrmommwmm��wi!�rnn�i�a>� �� ..�;.,mmuuumimiomi ��ti � m�oioioi��om�im�imimm�umww�ewiyiyiiuiuiuiuiuwwiuuuiumiuiuiv �u�muumHUHuuumHUHUHUHmwuuiuwiuiuwiuiuiuiuiuiuwiuiuiuiu � uam�nrurauruu�n�vuuuuuu
.....�..�...... Required Prior
�..�..�� ..._.._u.�
to Submittal to Board
Legal ® Attorney Name Sandra Kennedy
Controller ® Controller review is required for all Contracts $5,000.00 or more anc
greater than one year in length per the City Purchasing Policy
Purchasing ❑
Check the A p r ate Item Type Req t ire for All Submissions
Z Agreement LJ Contract F-1 Proposal F-1 Addendum
0 Professional Services E:1 Resolution
❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet
El Quote Opening ❑ Quote Award
Change Order No. ❑ C/O & PCA No. ❑ PCA
Ease/Encroach. ❑ Traffic Control
Other:
�e _yired Information
Company or Vendor Name Goodwill Industries of Michiana, Inc.
New Vendor
0 Yes ® No ❑ If Yes, Approved by Purchasing
MBE/WBE Contractor
[:] MBE ❑ WBE
Project Name
Brides ERN-Em_Dloyer Resourc imgator
_..e Nav
Project Number
.�....COIT.....................................u...w
FundingSource
�.�.....................................................�.�.�......... .........._
Account No.
� 404.1001.460.31.06���.......�.����..._��.��..� ..... � ..... �.
Amount
�..............................................................................................�_............................__............�..�.
$ 17,916.00
Terms of Contract
1/1/19-12/31/��� _.....�� �,m. ............w...�.
2019
Purpose/Description
Revises contracting g anziation due to Bridges or JJmerger with G ...
oodwi11 and
extends agreement through 2019 for balance of funds
® Required Contractor's Certification Form Attached (Non-
Non -Debarment, argent„ r� Iran etc.
_.....�...... .... ........
_..._.,�� Required For Change Orders Ong .�
a._ mm.....
Amount of ❑
❑
Increase
Decrease $
Previous Amount
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Current Percent of Change: %
New Amount
$