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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />November 1.. 2018 <br />inu <br />Department DCI <br />BPW Date November 13, 2018 Phone Extension 5845 <br />yry?yx+,MvvS£¢__mll, fit.3r9/!d/Nh'Ifs'u"S4ZB6'G�6JAPMrt11Y:rtu1f1l1YN%!NNNNNMmttPIPIPM�MB�+v�"vP!✓✓u��X�4CIdVl uXJ v1i�+.art � +.,xe� --.. "' )�YYdvvdv.dY,.d dt2GGWY. TflfiY E.'.rz�a'a'A�d,:w,n �f �a[a+--' '� '4—,.,uC,l('llpli l�W!MVikttlti✓ki�nm;NAY�e R+...'�^—»'�"�' ,,,,9✓: <br />.., wW.m. ............................. ._ <br />letuired Prior to Submittal to Boardmmm' <br />Legal ® Attorney Name Sandra Kennedy <br />Controller ❑ 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 />e ...... <br />Z Agreement <br />R Professional Services <br />El Bid Opening <br />El Quote Opening <br />E:] Change Order No. <br />0 Ease/Encroach. <br />Company or Vendor Name <br />iro riate Item Type <br />E1.16 <br />❑ Resolution <br />❑ Bid Award <br />E Quote Award <br />C/O & PCA No.. <br />Traffic Control <br />)r All: Sul <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />Required Information <br />Urban Enterprise Association of Sou <br />th uth Bend, Inc.(UEA) <br />Addendum <br />❑ Title Sheet <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />Project Name <br />2019 Agreement for Staff Support <br />Project Number <br />............. <br />Funding Source <br />........ <br />�.... ... ... __--------- .... ... .............. <br />Account No. <br />..... _ ............... _.....------ <br />211 <br />Amount <br />. $.40,00.... .. __.... .. ....... .. __.._�... .. <br />0 00 <br />Terms of Contract <br />I'll ......... .._ ,- .... ......... ---- ...................... -- --... <br />1/01/19-12/31/19 <br />Purpose/Description <br />__._ <br />Payment to DCI for staff services related to ___ <br />to the administering UEA's <br />Various programs and services <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non Debarment, E-Verifyp Iran, etc.) <br />Required For Change Orders Only <br />Amount of❑ Increase $ <br />❑N Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />® ® Pam <br />❑ ❑ <br />❑ ❑ <br />Dispersal After Approv <br />al <br />DCI <br />