Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 9/9/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: County Clerk/Elections
5) Department Contact: Mae Ross
6) Description: Poll Pad - Annual Software License & Support
7) PEID No: 406853
8) Req No:
9) Orgkey: 1101114030
10) Object Code: 5423000
11) Vendor: Hart Intercivic
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name: Maintenance & Repair
14) Fund #: 1101
15) Current Year Budgeted: 35,00.00
16) Current Year Projected: 29,026.00
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: 10/1/2024
23) Auto Renewal Contract: Yes
24) Bid No: NA
25) Contract End Date: 9/30/2025
26) Contract # Issued by Purchasing Department: CM24304
NOTES: HB1295 Requested