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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />7/14/16 <br />Timmer <br />Department DC] <br />BPW Date 7/26/16 Phone Extension 5841 <br />ired Prior to Submittal to <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ® <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type — Reqakffor All Submissions <br />® <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />F <br />Other: Amendment <br />red Information <br />Company or Vendor Name Oaklawn Psychiatric Center, Inc. <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/1NBE Contractor ❑ MBE ❑ WBE <br />MBEAINBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name Supportive Housing Rental Assistance <br />Project Number 16-JS-02 <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Continuum of Care (CoC) <br />212.1001.460.39.30 <br />100,644 <br />3/01/16 — 2/28/17 <br />Provide rental assistance and supportive services for homeless individuals <br />with severe mental illness <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran etc.) <br />Required For Change Orders Only <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Love <br />Dispersal After <br />