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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />8/24/16 <br />Timmer <br />Department DCI <br />BPW Date 9/13/16 Phone Extension 5841 <br />to Submittal to Board <br />Legal ® <br />Attorney Name <br />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 <br />— Required for All Submissions <br />❑ <br />Agreement <br />® Contract <br />❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />Other: Amendment <br />I Required Information <br />Company or Vendor Name AIDS Ministries/AIDS Assist of North Indiana Inc. <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBENVBE Contractor ❑ MBE ❑ WBE <br />MBENVBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name Emergency Shelter & Rapid Re -Housing Activities <br />Project Number 16-JE-02 <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />1/01/16 — 3/13/18 <br />Provide AM/AA clients with emergency shelter and housing <br />assistance <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 />7 <br />Love <br />Dispersal After Approva <br />