HomeMy WebLinkAboutSupplemental Attachments - 9/9/2019City of Waterloo
Finance Committee Preliminary Draft Invoice Report
For September 09 2019 Approval
Finance Committee Accounts Payable Open Invoice Report Total
As of Friday, September 06, 2019
EFT Transactions:
Add: Wellmark Claims
Add: Wellmark Claims
1, 320, 342.51
117,487.17
251,714.81
Workers Compensation Issued by TPA
Housing Authority Housing Assistance EFT's
Housing Authority Housing Assistance EFT's
Payroll
IWI Motor Parts
1,689,544.49 1
5,796.63
2,179.19
177.28
Bill Payment Total - Monday, September 09, 2019
1,697,697.59
Pay ant to Cc ncil members r related entities:
Item Coversheet
CITY OF WATERLOO
Council Communication
Page 1 of 1
Resolution approving completion of project and recommendation of acceptance of work for work performed by Boulder Contracting, LLC, of
Grundy Center, Iowa, in the amount of $484,332.11, in conjunction with the FY 2019 Bridge Repairs, Dubuque Road over Blowers Creek and
Greenhill Road over Trolle Car Trail, Contract No. 959, and receive and file a two-year maintenance bond.
City Council Meetin : 9/9/2019
Prepared: 9/3/2019
SUBJECT:
Submitted by:
Summary Statement:
Source of Funds:
Resolution approving completion ofproject and recommendation of acceptance of work for work
performed by Boulder Contracting, LLC, of Grundy Center, Iowa, in the amount of $484,332.11, in
conjunction with the FY 2019 Bridge Repairs, Dubuque Road over Blowers Creek and Greenhill Road
over Trolley Car Trail, Contract No. 959, and receive and file a two-year maintenance bond.
Submitted By: Jamie Knutson, PE, City Engineer
Boulder Contracting, LLC has completed the above referenced project in accordance with the plans
and specifications.
Transmitted also to the Clerk's Office is the Maintenance Bond that guarantees to remedy any defects
in workmanship or materials that may develop in said work within a period of two (2) years from the
date of the acceptance of the work under said contract.
Road Use Tax
https://waterloo.novusagenda.com/AgendaWeb/CoverSheet.aspx?ItemID=15710 9/4/2019
MAINTENANCE BOND
Bond Number 9723197
Know All Men By These Presents:
That Boulder Contracting, LLC of Grundy Center IA
as Principal, and the Westfield Insurance Company
as Surety, are held and firmly bound unto the City of Waterloo
, in the penal sum of Four Hundred Eighty-four
Thousand Three Hundred Thirty-two & 11/100ths ($ 484,332.11
)DOLLARS,
lawful money of the United States of America, for the payment of which, well and truly to be made, the Principal and Surety bind
themselves, their and each of their heirs, executors, administrators, successors and assigns, jointly and severally, firmly by
these presents.
Signed and delivered this 3rd day of September A D 2019
Whereas, the said Principal entered into a certain contract, dated the day of
, with the City of Waterloo
, to fumish all the material
and labor necessary for the construction of
2019 Bridge Repairs Dubuque Road Over Blowers Creek and Greenhill Road Over Trolley Car Trail
in the City of Waterloo , in conformity with certain specifications; and
Whereas, a further condition of said contract is that the said Principal should fumish a bond of indemnity, guaranteeing to
remedy any defects in workmanship or materials that may develop in said work within a period of
Two (2) years from the date of acceptance of the work under said contract; and
Whereas, the above work has been completed and accepted and if not accepted will be automatically accepted upon the
filing of this maintenance bond; and
Whereas, the said Westfield Insurance Company for a valuable consideration, has
agreed to join with said Principal in such bond or guarantee, indemnifying
City of Waterloo as aforesaid;
Now, Therefore, the Condition of this Obligaton is Such, that if the said Principaloes and shall, at his own cost and
expense, remedy any and all defects that may develop in said work, within the period of 1 WO (2) years from the
date of acceptance of the work under said contract, by reason of bad workmanship or poor material used in the construction of
said work, and shall keep all work in continuous good repair during said period, and shall in all other respects, comply with all
the terms and conditions of said contract with respect to maintenance and repair of said work, then this obligation to be null and
void; otherwise to be and remain in full force and virtue in law.
It is agreed that while the principal shall be and remain liable for failure to adhere to the specifications which form the basis
for the work, the surety, inasmuch as the original work was not bonded, shall be obligated only to assure the maintenance of the
work in the condition in which it existed at the time the work was accepted. Any obligation beyond this shall be that of only the
principal.
Boulder Contracting, LLC Principal
By 477
Westfield Insurance Company
Surety
4Lit
ncy
D. Baltutat, Attorney -in -Fact
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POWER # AND ISSUED PRIOR TO 06/07/16, FOR ANY PERSON OR PERSONS NAMED BELOW.
General
Power
of Attorney
CERTIFIED COPY
POWER NO. 1429172 00
Westfield Insurance Co.
Westfield National Insurance Co.
Ohio Farmers Insurance Co.
Westfield Center, Ohio
Know All Men by These Presents, That WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO
FARMERS INSURANCE COMPANY, corporations, hereinafter referred to individually as a "Company" and collectively as "Companies," duly
organized and existing under the laws of the State of Ohio, and having its principal office in Westfield Center, Medina County, Ohio, do by these
presents make, constitute and appoint
MARK E. KEAIRNES, JOSEPH 1. SCHMIT, JEFFREY R. BAKER, JILL SHAFFER, GREG T. LAMAIR, NANCY D. BALTUTAT,
PATRICK K. DUFF, CHRISTOPHER R. SEIBERLING, JOINTLY OR SEVERALLY
of WEST DES MOINES and State of IA its true and lawful Attorneys) -in -Fact, with full power and authority hereby conferred in its name,
place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings, or other instruments or contracts of
suretyship
LIMITATION: THIS POWER OF ATTORNEY CANNOT BE USED TO EXECUTE NOTE GUARANTEE, MORTGAGE DEFICIENCY, MORTGAGE
GUARANTEE, OR BANK DEPOSITORY BONDS.
and to bind any of the Companies thereby as fully and to the same extent as if such bonds were signed by the President, sealed with the corporate
seal of the applicable Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attorney(s)-in-Fact may do in
the premises. Said appointment is made under and by authority of the following resolution adopted by the Board of Directors of each of the
WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY:
"Be It Resolved, that the President, any Senior Executive, any Secretary or any Fidelity & Surety Operations Executive or other Executive shall
be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and act for
and on behalf of the Company subject to the following provisions:
The Attorney -in -Fact. may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and
deliver, any and all bonds, recognizances, contracts, agreements of indemnity and other conditional or obligatory undertakings and any and all
notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such
Attorney -in -Fact shall be as binding upon the Company as if signed by the President and sealed and attested by the Corporate Secretary."
"Be it Further Resolved, that the signature of any such designated person and the seal of the Company heretofore or hereafter affixed to any
power of attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signatures or facsimile
seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is attached." (Each adopted at a meeting
held on February 8, 2000).
!n Witness Whereof, WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE
COMPANY have caused these presents to be signed by their National Surety Leader and Senior Executive and their corporate seals to be hereto
affixed this 07th day of JUNE A.D., 2016 .
Corporate
Seals ,t•`4,SYR:(pc'�.
Affixed lift .A. + � s
1 F.. aL.C1L y .o iit
State of Ohio
County of Medina ss.:
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WESTFIELD INSURANCE COMPANY
WESTFIELD NATIONAL INSURANCE COMPANY
OHIO FARMERS INSURANCE COMPANY
By:
Dennis P. Baus, National Surety Leader and
Senior Executive
On this 07th day of JUNE A.D., 2016 , before me personally came Dennis P. Baus to me known, who, being by me duly sworn, did
depose and say, that he resides in Wooster, Ohio; that he is National Surety Leader and Senior Executive of WESTFIELD INSURANCE
COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY, the companies described in and which
executed the above instrument; that he knows the seals of said Companies; that the seals affixed to said instrument are such corporate seals; that
they were so affixed by order of the Boards of Directors of said Companies; and that he signed his name thereto by like order.
Notarial,,,,,,
Seal ` kA—4,
Affixed P �11Ui/ F%'
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State of Ohio
County of Medina ss.:
David A. Kotnik, Attorney at Law, Notary Public
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2igeeedir&o.
My Commission Does Not Expire (Sec. 147.03 Ohio Revised Code)
I, Frank A. Carrino, Secretary of WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS
INSURANCE COMPANY, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said
Companies, which is still in full force and effect; and furthermore, the resolutions of the Boards of Directors, set out in the Power of Attorney are
in full force and effect.
In Witness Whereof, I have hereunto set my hand
September,..0.A'"'".o19
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I ask
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BPOAC2 (combined) (06-02)
and affixed the seals of said Companies at Westfield Center, Ohio, this 3rd
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Frank A. Carrino, Secretary
Secretary
day of
APPLICATION
FOR
VARIANCE TO NOISE ORDINANCE
APPLICANT'S NAME: C
APPLICANT'S ADDRESS:
APPLICANT'S PHONE #:
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ANTICIPATED DATE OF VARIANCE:
NAME OF EVENT:
TIMES OF DAY OF VARIANCE:
GEOGRAPHICAL LOCATION OF VARIANCE: porhtrAc
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DISTANCE OF ACTIVITY FROM RESIDENTIAL PROPERTIES: OL I l� Chb V S
loo
fnvjafc tuplarhotil) he psis .tea 6 otxv l -h Com.
PLEASE EXPLAIN THE EVENT REQUIRING THE VARIANCE AND BE SPECIFIC,
INCLUDE GEOGRAPHICAL LOCATION, AND WHAT ACTUALLY WILL EXCEED THE
NOISE ORDINANCE, SUCH AS A BAND PLAYING, PA SYSTEM, ETC.
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CITY COUNCIL ACTION: Police Dept. Recommendation
f
APPROVAL: APPROVAL: V..
DENIAL:
DENIAL:
DECIBEL LEVEL: Y46
CAN7"S'
'FIyI Al
FOR
VAIUANCE TO NOISE ORDINANCE
Waterloo Softball Association- Jake Schaefer, President
L1C sI S: 1139 Josephine
`PSC Q 319-231-0659
DATE OF VARIANCE: Saturday, September 21, 2019
OF EVENT: Hometown Heroes Softball Tournament
OF DAY OF VMUANC
6:OOpm-10:OOpm
ATION OF VARIANCE: Hoing-Rice Softball Complex
1139"Jose .hine Waterloo Iowa 50703
OF A iT f PROI'E
North of Complex -400 ft, South of Complex-559ft, West of Complex - 672ft
G
NOISE, 0 Ii
Q G VA A E SPECIFt ,
AT1ON, AND WHAT ACTUALLY WILLD
SUCH AS A BANDPLAYING, PA SYSTEM, ETC.
The Waterloo Softball Association is hosting a Home Town Heroes charity
softball tournament in honor of Deputy Tim Petersen, and Fire Fighter Greg
Freshwater. The tournament and post tournament music provided by the
local band RED LINE is an effort to raise funds for the Peace Officer Pavilion
project at the complex and paramedic scholarships. The live music is going to
set up on field #4 with music being played from 7:OOpm-10:OOpm.
nt's i
August, 28th 2019
Date
+O oda.. AEON: Policet.'
'ROV APPROVAL:
DECIBEL Ll
Inaugural "Hometown Heroes" Fundraiser Men's & CO-ED Softball Tournament. Limit to 24 teams.
1 Day: September 215t, 2019 (rain date, September 22"d) Hoing-Rice Softball Complex. Waterloo, IA.
Tournament Director: MoIIy Brouwer (319) 240-7574.
Registration: $200. Register via Google Form on Waterloo Softball website.
Mail Checks (Payable to Tim Petersen Memorial) to MoIIy Brouwer PO BOX 823. Hudson, IA 50643.
Deadline: Must receive entry fee by September 13th, 2019.
• 2 game guarantee. 55 -minute time limit. No new inning starts after 55 minutes.
• Number of teams and/or weather may change format of tournament.
• CO-ED: 5 guys & 5 girls or 6 guys & 6 girls.
• ASA approved bats & balls
• Hit your own balls. Guys hit 12" 52/300 ball. Girls hit 11" 52/300 ball.
• 1-1 Count, no courtesy. Mat only is a strike. 6-10ft. pitch height.
• Run Rule: 20 after 3, 15 after 4 & 10 after 5.
• Guys 4 homeruns then out, Girls unlimited home runs.
• Winning team umpires next game on their field. If winners play right away, losing team will umpire.
Will have umpires for money games.
• No metal or metal tip cleats. Complex Rule.
• Complex has concession stand with beer and food. NO outside drink or food allowed.
• Will have raffle prizes and 50/50 raffle.
BLACK HAWK COUNTY HERIFF* OFFICE
Tim Petersen; Black Hawk Co Sheriff's Deputy.
Tim worked in the Jail Division and the Patrol
Division. He was also assigned to the Water Safety
Patrol and the Motorcycle Patrol Unit.
Tim loved his work. In his free time, he enjoyed
playing softball and riding his Harley. Tim was an
avid Iowa Hawkeyes and Chicago Cubs fan. Most of
all, he loved spending time with his wife and son.
On August 4th 2015, Tim was killed in a motorcycle accident in Waterloo. He
leaves behind his wife Katy, his son Jax, several family members and friends. We never
realized the impact that he had on the community until he left in such a sudden way.
Greg Freshwater; Waterloo Firefighter
Greg joined the Waterloo Fire Department in November of 2016.
As a new firefighter, he was rotating between stations to
familiarize himself with the equipment and department
operations, and he was also taking additional training.
Greg came from a firefighting family. His Father Jeff Freshwater
and his uncle Marty Freshwater were also firefighters for many
years. In August of 2017, Greg was involved in a tragic accident
that took his life at a young age of 27.
Our Mission: Peace Officer Pavilion
The Peace Officer Pavilion Project was
derived from conversations with Black
Hawk County Deputy Tim Petersen in
the summer of 2015. A vision of
sustaining a first rate facility that
keeps the memory of our past heroes
present in our lives, was the mindset
of the project from day one. The
building of a Peace Officer Pavilion
shelter to protect players and fans during all forms of Iowa weather, an additional
memorial for recognition of our fallen local heroes and a spruce up of the
commemorative complex's playing areas is what Tim had in mind. Unfortunately Deputy
Petersen was killed a few weeks later in an off-duty motorcycle accident in August 2015
before he could see his vision of the project become a reality.
Since Deputy Petersen's death many have carried his torch with motorcycle rides,
softball tournaments & a memorial brick drive to help move the fundraising needle.
With the generous support of the local police, fire & Sheriffs unions, family & friends of
local fallen peace officers as well as local baseball/softball teams we have raised
$80,000 to date.
TRAVEL REQUEST
CITY OF I/WATERLOO
NAME(S) AND POSITION(S):
FINANCE DEPT.
LINE ITEM USED
FY II) BUDGETED
EXPENDED YTD
THIS REQUEST
LEFT AFTER THIS
REQUEST
DATE
Original - Clerk/Finance
STAFF ONLY
010 03 8400 1346
5,500.0 u
0.00
1 j cl 1 CI Cd -05'
Copy - Department
Michelle Weidner, Chief Financial Officer
DATE:
9/5/2019
NAME OF CLASS / MEETING:
League of Cities Annual Conference
DESTINATION:
Dubuque, IA
DEPARTURE POINT
IF NOT WATERLOO:
DEPARTURE DATE:
9/25/2019
PURPOSE OF TRAVEL/TRAINING:
Attend League of Cities Annual Conference
RETURN DATE:
9/27/2019
WILL TRAVEL REQUIRE ADDITIONAL PERSONNEL:
YES
DATE(S) OF MEETING:
9/25/2019-9/27/2019
NO
COST $
METHOD OF TRAVEL:
CITY VEHICLE
AIRFARE
DEPARTING FROM:
PRIVATE VEHICLE
ESTIMATE OF COST:
300.00 LODGING
55.00 MEALS
255.00 REGISTRATION
40.00 MILEAGE/FUEL
30.00
TOTAL FOR ALL: $ 655.00
TAXI
PARKING
AIRFARE
RflISC/TOLLS
BUDGET LINE ITEM: 010 03 8400 1346
x GRANT REIMBURSABLE
YES NO
x
YES NO
REQUIRED CERTIFICATION
TOTAL: $ 655.00
PER PERSON
I BELIEVE THIS TRIP SERVES A PUBLIC PURPOSE
AND IS NECESSARY AND BENEFICIAL TO THE
CITY OF WATERLOO
DEPARTMENT HEAD
APPROVE THIS TRAVEL REQUEST
...0--1244.54Caa?
MAYOR
91- 61-791
DATE DATE
K:\Shared Goodies\Forms\Travel Request Form January 2010
RAVEL flRMA, EST
CITY OF WATERLOO
FINANCE DEPT. STAFF ONLY
LINE ITEM USED
FYav BUDGETED
EXPENDED YTD
THIS REQUEST
LEFT AFTER THI5
REQUEST
DATE
Original - Clerk/Finance
260 /1 Sao /3cgi
_good
s
tau
cimu
Copy - Department
NAME(S) AND POSITION(S):
Tina Schellhom, Electrical Foreman; Matt Vlasak, Signal
Tech Foreman; Craig Hintzman, Signal Tech ll; Nate
Alderman, Electrician; Kelby Haines, Electrician; Scott
Buchan, Electrician
NAME OF CLASS / MEETING:
Electrical Calculations & Common Violations
DATE:
October 16, 2019
DESTINATION: Waterloo, Iowa
DEPARTURE POINT
IF NOT WATERLOO:
DEPARTURE DATE:
October 16, 2019
RETURN DATE:
October 16, 2019
DATE(S) OF MEETING:
October 16, 2019
PURPOSE OF TRAVEL/TRAINING:
Satisfies the requirement for the new State of Iowa Electrical Licensing law. All of the calculations used in the
electrical industry including box fill, sizing, raceway fill, derating, romex and many other calculations. Finding
problems and solutions to the most common mistakes that are made in the wiring of new facilities.
WILL TRAVEL REQUIRE ADDITIONAL PERSONNEL:
�--
X COST $
YES NO
4
METHOD OF TRAVEL:
CITY VEHICLE
AIRFARE
DEPARTING FROM:
PRIVATE VEHICLE
ESTIMATE OF COST:
LODGING
MEALS
$900.00 REGISTRATION
MILEAGE/FUEL
TOTAL FOR ALL: $ 900.00
TAXI
PARKING
AIRFARE
MISC/TOLLS
BUDGET LINE ITEM: 266-17-71204 1,346,
GRANT REIMBURSABLE
YES NO
X REQUIRED CERTIFICATION
YES NO
TOTAL: $ 150.00
PER PERSON
I BELIEVE THIS TRIP SERVES A PUBLIC PURPOSE
AND IS NECESSARY AND BENEFICIAL TO THE
CITY OF WATERLOO
antdefiAtee
DEPARTMENT HEAD,
7/s'
flA\dared Goodies\For-rns\Travel Request Form January 2010 DATE
I APPROVE THIS TRAVEL REQUEST
MAYOR
TRAVEL REQUEST
CITY OF WATERLOO
NAME(S) AND POSITION(S):
Sgt. Michael Girsch & Officer Troy Wilson
FINANCE DEPT.
LINE ITEM USED
FY _2020 BUDGETED
EXPENDED YTD
THIS REQUEST
LEFT AFTER THIS
REQUEST
DATE
Original - Clerk/Finance
DATE:
STAFF ONLY
01041-1100-1346
.0, 00 c
'1/3 8�
1676-o
is-
ellooec
WG4) 9.3 --i?
Copy - Department
September 3rd, 2019
NAME OF CLASS / MEETING:
High Threat CQB Swat Training
G ws 6 OLLdt .r cies L. c E SP &c «n- WMM- raj
Ake
�ra f=as
DESTINATION: Waterloo, Iowa
DEPARTURE POINT
IF NOT WATERLOO:
DEPARTURE DATE:
9/24/19
Return Date:
9/26/19
DATE(S) OF MEETING:
September 24 -26th, 2019
PURPOSE OF TRAVEL:
Captain McGeough is requesting to send Sgt. Girsch and Officer Wilson to High Threat CQB Swat Training in Waterloo
Iowa September 24 -26th, 2019. Both Officers are members of the Waterloo Police Department Tactical Unit as well as
Firearms Instructors for the department. This school will work on clearing structures safely and sudden high threat
encounters as well as spontaneous officer rescue tactics. The skills learned will be taken back to the Tactical Unit as well
as the rest of the department at training. The cost of this school will not exceed $550.00.
WILL TRAVEL REQUIRE ADDITIONAL PERSONNEL:
METHOD OF TRAVEL:
X CITY VEHICLE
AIRFARE
x COST $ N/A
YES NO
DEPARTING FROM:
PRIVATE VEHICLE
ESTIMATE OF COST:
$0.00 LODGING
$0.00 MEALS
$550.00 REGISTRATION
$0.00 MILEAGE/FUEL
TOTAL FOR ALL: $ 550.00
TAXI
PARKING
AIRFARE
MISC/TOLL S
BUDGET LINE ITEM:
X GRANT REIMBURSABLE
YES NO
x
YES NO
REQUIRED CERTIFICATION
TOTAL: $ 275.00 PER PERSON
I BELIEVE THIS TRIP SERVES A PUBLIC PURPOSE
AND IS NECESSARY AND BENEFICIAL TO THE
CITY OF WATERLOO
DEPT RTMENT HEA
D9031q
DATE DATE
1
I APPROVE THIS TRAVEL REQUEST
rte,
MAYOR
?RA V EL REQUEST
CITY OF WATERLOO
NAME(S) AND POSITION(S):
Rudy Jones -Community Development Director
NAME OF CLASS / MEETING:
State and Entitlement Meeting
DATE:
9-3-201
FINANCE DEPT
LINE ITEM USED
FY€M 0 BUDGETED
EXPENDED YTD
THIS REQUEST
LEFT AFTER THIS
REQUEST
INATP
Original - Clerk/Finance
. STAFF ONLY
/4,t 3,2 CD /3414
/ acV u`-‘-
745"--('-%
Copy - Department
DESTINATION:
Des Moines, Iowa
DEPARTURE POINT
IF NOT WATERLOO:
DEPARTURE DATE:
September 17, 2019
PURPOSE OF TRAVEL/TRAINING:
RETURN DATE:
September 17, 2019
DATE(S) OF MEETING:
September 17, 2019
The Iowa Economic Development Authority and the Iowa Finance Authority administer the state allocation of
CDBG and HOME. The state is hosting a meeting with all the entitlement representatives who administer
CDBG and HOME. These meetings are an opportunity for all of us to discuss administrative challenges and
innovative projects.
WILL TRAVEL REQUIRE ADDITIONAL PERSONNEL:
x COST $
YES NO
METHOD OF TRAVEL:
x CITY VEHICLE
AIRFARE
PRIVATE VEHICLE
DEPARTING FROM: 620 Mulberry Street
ESTIMATE OF COST:
LODGING
15.00 MEALS
REGISTRATION
MILEAGE/FUEL
100.00
TOTAL FOR ALL: $ 115.00
TAXI
PARKING
AIRFARE
MISC/TOLLS
BUDGET LINE ITEM: 224- 32- 5850.1346
GRANT REIMBURSABLE
YES NO BG21 A.ADMN
x REQUIRED CERTIFICATION
YES NO
TOTAL: $ 115.00
I BELIEVE THIS TRIP SERVES A PUBLIC PURPOSE
AND IS NECESSARY AND BENEFICIAL TO THE
CITY OF WATERLOO
/
DEPARTMENT HEA
K:\Shared Goodies\Forms\Travel Request Form January 2010
PER PERSON
I APPROVE THIS TRAVEL REQUEST
MAYOR
5
DATE DATE