Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 11/4/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Professional Services
5) Department Contact: Veronica Van Horn
6) Description: Public Official Bond Renewal for District Clerk & Tax Assessor/Collector
7) PEID No: 719491
8) Req No:
9) Orgkey: 6130-151431
10) Object Code: 5491700
11) Vendor: GIA Insurance Agency, LLC
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name: Self Insurance
14) Fund #: 6130
15) Current Year Budgeted:
16) Current Year Projected: $3,979.00
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: 12/6/2024
23) Auto Renewal Contract: Yes
24) Bid No: NA
25) Contract End Date: 12/06/2025
26) Contract # Issued by Purchasing Department: CM25038 - J. Kinard & CM25037 - C. Johnson
NOTES: