HomeMy WebLinkAboutResolution #3991 - amending the purchase policy RESOLUTION NO. 3991
A RESOLUTION AMENDING THE PURCHASING POLICY FOR THE CITY OF CANTON,
ILLINOIS
WHEREAS departments for the City of Canton must procure goods and services for the
efficient operation of their departments; and
WHEREAS, there is a need for a written policy that provides general reference on the process
to procure goods and services by the various departments; and
WHEREAS, on April 17, 2012, by a Resolution No. 3981, the City adopted a written
Purchasing Policy; and
WHEREAS, the head of each department, as well as the City Council of the City of Canton,
Illinois, has reviewed and discussed the terms of the Amended Purchasing Policy as to travel expenses,
a copy of which is attached hereto and incorporated herein as Exhibit A; and
Whereas, the City Council of the City of Canton, Illinois, has determined that it is desirable
and, in the best interest of the City of Canton, to amend said Purchasing Policy as to travel expenses.
THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COUNCIL OF THE CITY
OF CANTON, ILLINOIS, AS FOLLOWS:
1. That the Amended Purchasing Policy, which is attached hereto and incorporated herein as
Exhibit A, is hereby approved in the form attached as Exhibit A.
2. That the City staff, may, from time to time, propose changes to the Council in the Purchasing
Policy to streamline the process and provide for the highest level of accountability and
transparency in the expenditure of public funds.
3. That this Resolution shall be in full force and effect immediately upon its passage by the City
Council of the City of Canton, Illinois, and approval by the Mayor thereof.
PASSED by the City Council of the City of Canton, Illinois, at a regular meeting this day of June,
2012, upon a roll call vote as follows:
AYES: Aldermen Pickel, Hartford, Schenck, Pasley, West, Fritz, Ellis
NAYS: None
ABSENT: Alderman Nelson
APPROVE~
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Kevin R. Meade, ayor
ATT ST:
Di Pavley, City Cler
City of Canton
Purchasing Policy
Adopted: February 21, 2012
Revised: June 19, 2012
Introduction:
The purpose of this document is to provide a purchasing policy and procedure as guidance for
the City of Canton's operating departments in procuring goods and services. This policy is intended
for use by City personnel as a general reference and will be revised for departmental distribution as
policies and procedures require revisions or clarification. The policies and procedures set forth in the
manual are meant to serve as guidelines and will not be applicable to every purchasing situation that
may arise. When purchases that are not covered by this manual are necessary, they should be made in
accordance with the objectives outlined below.
1. Purchasing services, commodities, materials, and equipment of sufficient quality at the most
economical price available and which best meet the needs of the City;
2. Purchasing in an open, forthright, and ethical manner;
3. Purchasing in a manner which will comply with all local, state, and federal laws; and
4. Purchasing in a timely manner so that services, commodities, materials, and equipment are
available when needed.
Purchasing Function and Responsibilities:
Sections 8-9-1 and 8-9-2 of the Illinois Municipal Code (65 ILCS 5/8-9-1) establish the dollar
value for requiring sealed bids for public works contracts and municipal supplies. The City Council
may by a 2/3 majority vote waive bids and negotiate purchases. The City currently utilizes the State
threshold for sealed bids. Effective August 5, 2005, Public Act 94-0435 increased the municipal bid
threshold from $10,000 to $20,000.
The following amounts shall be the maximum amounts of city funds which may be expended
on unbud eg ted items by the listed officials on official business for the city without prior council
approval:
Mayor $3.000.00
Department Heads $2,000.00
The following amounts shall be the maximum amounts of city funds which may be expended
on unbud e~ ted items by the listed officials on official business for the city on an emergency
situation without prior council approval:
Mayor $10.000.00
Department Heads $5,000.00
City Ordinance 1986 Article 1-16-3 of the Canton City Code states as follows: "Powers and
Duties: The City Administrator shall be responsible to Mayor for proper administration of
all affairs of the city. In discJaarging this responsibility the City Adrrtinistrator shall, as
directe~l by the mayor: (A) Supervise and coordinate the administrative function of all
departments, offices and agencies of the city... (F) Coordinate activities between the
departments to ensure efficient utilization of resources and mcrximize interdependent
coordination. (M) Oversee the operations of the City Administration department providing
assistance when needed."
Procedure:
The Mayor and each Department Head shall be responsible for purchasing items up to their respective
limits while following these prescribed procedures for his/her department. All purchases much meet
department requirements and are to be purchased at competitive prices.
It is the desire of the City to purchase from Canton vendors whenever possible. This can be
accomplished by insuring that local vendors who have goods and services available which are needed
by the City are included in the competitive shopping process which will precede most purchases. The
City has a responsibility to its residents, however, to insure that the maximum value is obtained for
each public dollar spent. It is assumed that local vendors who wish to do business with the City will
offer the lowest possible quote for the item being purchased.
The City Purchase Order Form must be completed and signed by the Department Head by entering the
necessary data under the procedures established in this policy. In order to insure expeditious
processing for purchase order it is important that all forms are completed accurately by the
requisitioning department.
Purchases and Contracts Under $1,000
Items and contracts $1,000 or less are not subject to any bid/proposal requirements and shall be at
the discretion of the Department Head or his/her designee to determine if the price is fair and
equitable. However, as time allows price comparisons may be obtained. When items purchased
are of a varying nature and quantity, as is the case with office supplies and auto parts, standard
discounts will be negotiated with several suppliers.
Purchases and Contracts Between $1,000 and $5,000
Items and contracts in excess of $1,000 but less than $5,000 may be purchased after obtaining two
or more verbal price quotations. These quotations may be obtained via telephone or in person from
the vendors and must be submitted on a Price Inquiry Form with the Purchase Order Form.
Purchases and Contracts Between $5,000 and $10,000
Items and contracts in excess of $5,000 up to $10,000 may be obtained after receiving two or more
written quotations when and where possible (or if the situation dictates, oral quotes, followed by
vendor written confirmation). A quotation that is submitted via a facsimile machine by the bidder
shall meet this requirement. These quotes must be submitted with the Purchase Order Form.
Considerations for Purchases Less Than $10,000 Per Item:
Purchase standard "off the shelf
' items rather than special or custom made products.
Whenever practicable, buy in quantities which are standard, (i.e.: a dozen, a full carton, etc.) to
realize better prices. Also, care should be taken to consider the shelf life of the item needed.
Generally speaking, when making purchases less than $10,000 per item, the specifications, terms
and conditions, and other requirements are usually simplified compared to formal competitive
bidding. This method of purchasing saves staff time when compared to the process required for
formal bidding.
Purchases and Contracts Over $10,000 Per Item
Formal bids/proposals are designed to protect the interest of the bidder, as well as the City of
Canton and to do away with favoritism by reinforcing the concepts of openness and impartiality.
The following guidelines shall be followed when soliciting for purchases and contracts in excess of
$10,000 per item:
1. Bids/Proposals - Services, Commodities, Materials, or Equipment in Excess of $10,000
Except as otherwise specified, all services, commodities, materials, or equipment that cost in
excess of $10,000 shall require solicitation of competitive bids/proposals. This process may
be waived in emergencies or where it is impracticable.
2. Advertisement for Bids/Proposals
Where required by state or local law or this policy, the City shall advertise by invitation or
publication in newspaper or trade journals for sealed bids/proposals for any proposed work,
materials, commodities, or equipment. Such advertisement shall be inserted not less than 10
days or more than 30 days before the date set for opening bids/proposals. The notice for
bids/proposals need give only a general description and/or plans and specifications shall be on
file in the Administrative Office for inspection. The advertisement may call for each bid to be
accompanied by a cashier's or certified check or bid bond in an amount equal up to 10 percent
of the bid, to secure said bid. However, there shall be no duty on the part of the City, or its
employees, to convert said check or bond into cash, and the bidder shall accept all
responsibility for failure of the bank to pay or honor sums.
Said bids/proposals shall be opened by the City Clerk and reported to the City Administrator,
the Mayor, and City Council. The contract shall be let to the lowest responsible bidder, except
that all bids/proposals may be rejected and any advertisement shall so state.
It should be noted that if only one bid/proposal is received a contract may still be awarded.
Care must be taken to make sure the bid/proposal meets all statutory procedures and that the
price received is fair and reasonable. This will help avoid any claims of impropriety.
In the event of a tie between two vendors, the contract will be awarded after taking into
consideration such factors as past performance of the vendor, locality, delivery time, and any
other factors deemed appropriate.
Public Works Contracts in Excess of $10,000
1. Bids/Proposals - Public Works Contracts Between $10,000 and $20,000
Contracts in excess of $10,000 up to $20,000 may be obtained after receiving two or more
written quotations when and where possible (or if the situation dictates, oral quotes, followed
by vendor written confirmation). A quotation that is submitted via a facsimile machine by the
bidder shall meet this requirement. These quotes must be submitted with the check requisition
form.
2. Bids/Proposals - Public Works Contracts in Excess of $20,000
Section 8-9-1 of the Illinois Municipal Code requires that a municipality go out to bid for any
work or other public improvement which is not to be paid for in whole or in part by special
assessment or special taxation when the expense thereof shall exceed $20,000 (65 ILCS 5/8-9-
1). The municipality must let the contract to the lowest responsibility bidder in manner and
form as is prescribed by Ordinance, except that any such contract may be entered into without
advertising for bids by a vote of two-thirds of the Trustees elected. Whenever, the requirement
for advertising for bids is waived by the City Council Members, the reason for the waiver must
be stated publicly. Acceptable reasons for waiver of the bid requirements include but are not
limited to:
a. an emergency purchase;
b. only one vendor available;
c. equipment standardization;
d. the technical nature of the item makes competition impractical;
e. use of joint governmental purchasing program;
f. intergovernmental cooperation governing public improvement projects; or
g. competitive unit prices from a previously awarded contract.
3. Bids/Proposals - Public Works Contracts in Excess $100,000
Contracts in excess of $100,000 follow the same rules as contracts in excess of $20,000, but the
contract has to be awarded to a company that participates in an approved BAT (Bureau of
Apprenticeship Training) program, as per Resolution No 3748.
4. Advertisement for Bids/Proposals
Where required by state or local law or this policy, the City shall advertise by invitation or
publication in newspaper or trade journals for sealed bids/proposals for any proposed work,
materials, commodities, or equipment. Such advertisement shall be inserted not less than 10
days or more than 30 days before the date set for opening bids/proposals. The notice for
bids/proposals need give only a general description and/or plans and specifications shall be on
file in the Administrative Office for inspection. The advertisement may call for each bid to be
accompanied by a cashier's ar certified check or bid bond in an amount equal up to 10 percent
of the bid, to secure said bid. However, there shall be no duty on the part of the City, or its
employees, to convert said check or bond into cash, and the bidder shall accept all
responsibility for failure of the bank to pay or honor sums.
Said bids/proposals shall be opened by the department head and reported to the City
Administrator, the Mayor, and the City Council. The contract shall be awarded to the lowest
responsible bidder, except that all bids/proposals may be rejected and any advertisement shall
so state.
It should be noted that if only one bid/proposal is received a contract may still be awarded.
Care must be taken to make sure the bid/proposal meets all statutory procedures and that the
price received is fair and reasonable. This will help avoid any claims of impropriety.
In the event of a tie between two vendors, the contract will be awarded after taking into
consideration such factors as past performance of the vendor, locality, delivery time, and any
other factors deemed appropriate.
Emergency Purchases
Emergency purchases are made to protect public health, safety, and welfare that are threatened due
to an event that has occurred or may soon occur. An emergency purchase shall be considered to be
warranted when the purchase of supplies, equipment, or services is necessary to maintain
continuation of vital City services.
When an emergency exists, the Department Head or his/her designee should inform the City
Administrator or his/her designee not later than noon of the work day following the emergency
purchase as to what was required to correct the emergency situation. The City Administrator or
his/her designee will notify the City Council by e-mail within 24 hours of receiving notification of
the emergency and what was required to correct the emergency situation.
While the need for occasional emergency purchases is recognized, this practice shall be
discouraged as much as possible. On-going materials and services utilized by the City should
never be considered as an emergency purchase. Poor planning, inaccurate usage history, and
inadequate forecasting, however, are often responsible for expedited purchases and are not bona
fide emergency situations. Planning in advance for the needs of the department is the key to
avoiding emergency purchases.
Emergency purchases are normally costly and should be kept to a minimum. They are usually
made hurriedly, on a non-competitive basis and at premium prices. Most vendors charge a
premium when goods must be obtained immediately. By avoiding emergency orders, the City will
save money.
Petty Cash Purchases
A petty cash fund has been established to expedite miscellaneous small purchases. The use of petty
cash funds is authorized for reimbursement purposes. Petty cash funds should not exceed a single
purchase amount of $50 unless previously authorized by the City Administrator, City Treasurer, or
City Comptroller.
Use of petty cash is intended for convenience and/or unforeseen purchases. It is not intended to
circumvent the established purchasing procedures or to avoid proper planning of activities. Petty
cash should be limited to:
1. The purchase of items which are not ordinarily on hand in the City.
2. The payment of handling or C.O.D. charges for goods delivered.
3. Small purchases that must be made in a timely fashion.
In order to receive reimbursement, it is mandatory to present an itemized receipt obtained from the
vendor and complete a Petty Cash Slip. Petty cash is available from the City Treasurer or the City
Comptroller.
Credit Card Purchases
Prior to any employee receiving a City credit card, the employee is required to sign a Cardholder
Agreement form. After an employee signs the Cardholder Agreement form, it may take up to six
weeks to process and obtain the card. Employees with a City credit card will be asked to sign a
new Cardholder Agreement every April prior to the start of a new fiscal year. Refusal to sign the
Cardholder Agreement will result in immediate cancellation of the City credit card. Cancellation
of a City credit card can be requested by an employee or their Department Head at anytime. Upon
separation from employment with the City, the credit card must be returned to the City
Treasurer/City Comptroller for cancellation and disposal.
When purchases are made on any City credit card, an itemized receipt must be attached to the
statement in order for the City Treasurer/City Comptroller to process the payment. If a receipt is
not available, a Missing Receipt Statement must be filled out and signed by the Department Head
prior to submitting to the City Treasurer/City Comptroller. If not approved by the Department
Head, the employee is responsible for paying the total amount of the purchase.
The City credit card may not be used for the following purchases:
• Meals and related expenses while cardholder is in a per diem travel status
• Alcohol or any substance, material or service which violates policy, law or regulations
pertaining to the City of Canton
• Personal expenses
• Cash advances
• Prescription drugs/controlled substances
• Equipment with a trade-in
• Any purchase that is prohibited by current City purchasing policies and procedures
Only the approved cardholder may use the City credit card. Use by anyone other than the
cardholder is prohibited. The card is NOT transferable between cardholders or departments.
Purchasing card transaction must not be split to divide a larger purchase, which is over the
cardholder's single purchase limit.
The cardholder shall retain a copy of the original itemized charge slip/receipt or invoice for all
goods and services purchased, and any other information related to the purchase. These items need
to be forwarded on to the Department Head as soon as possible for inclusion with their monthly
report.
It is the responsibility of the cardholder to attempt to resolve any disputes with a vendor. If a
resolution is not possible, the cardholder should report the problem to the Department Head and the
City Treasurer/City Comptroller.
The cardholder is responsible for reporting the loss/theft of the card immediately to Wells Fargo
(1-800-231-5511), the Department Head, City Administrator and the City Treasurer/City
Comptroller.
Employees using their own credit cards to make purchases on the City's behalf should follow the
same guidelines stated above. Employees should not use their own credit cards unless it is an
emergency situation or they have prior approval from their Department Head. To the degree
practicable, City issued credit cards shall be utilized.
Misuse of the card is considered a violation that could result in disciplinary action. If it is
determined that a card has been used inappropriately, the card will be immediately cancelled
and a full reimbursement for those charges will be made to the City.
Expenditure Reimbursement Guidelines
Employees must complete an Expense Report Form with attach itemized receipts and obtain
Department Head approval. If a receipt is not available, a Missing Receipt Statement must be
filled out and signed by the Department Head prior to submitting to the City Treasurer/City
Comptroller. If not approved by the Department Head, the employee is responsible for paying the
total amount of the purchase. The Department Head needs to submit a Purchase Order with the
Expense Report Form and itemized receipts to the City Treasurer/City Comptroller to process the
payment.
The City will not reimburse the following expenses:
• Meals and related expenses while cardholder is in a per diem travel status
• Alcohol or any substance, material or service which violates policy, law or regulations
pertaining to the City of Canton
• Personal expenses
• Prescription drugs/controlled substances
• Equipment with a trade-in
• Any purchase that is prohibited by current City purchasing policies and procedures
Travel Expenses
Reimbursable travel expenses include only those expenses incurred while traveling on official City
business. Expenses will be reimbursed per the guidelines located at U.S. General Services
Administration (www.gsa.gov) unless otherwise stated.
Milea~e
Prior to traveling, employees need to receive approval from their Department Head. If the
Department Head can make a City vehicle available, then the Department Head should do so.
Employees utilizing personal vehicles shall carry their own insurance with business use protection.
The employee's personal vehicle insurance coverage is considered primary. Google Maps will be
used to determine mileage among all points of travel. All vicinity mileage must be justified with an
explanation on the Expense Report Form. Employees are still expected to record beginning and
ending odometer readings for exact mileage in the event of a traffic detour. Mileage
reimbursement will be refunded at the current rate dictated by the IRS.
Unallowable Miles
Unallowable miles cannot be included in an employee's request for mileage reimbursement.
This includes non-chargeable commuting miles between home and the employee's regular
work site.
• Mileage between the last destination of the day and home cannot be included for
reimbursement unless there is remaining mileage after the regular commuting miles
have been deducted. Employees who include unallowable miles in their request for
mileage reimbursement will be subject to disciplinary action.
• Mileage will not be reimbursed for requests of 5 miles or less for any segment of a trip.
Management Review/Approval
• Approval of a mileage reimbursement request is required from an employee's
Department Head ~rst-line approver), City Administrator, City Treasurer, and City
Comptroller. Not having an adequate review process prior to submitting for payment
increases the risk that the taxpayer dollars are not being used efficiently or prudently.
• The employee needs to submit the mileage reimbursement request on the Expense
Reimbursement form.
• The Expense Report form is reviewed by the Department Head and approved with an
original signature. The Department Head needs to fill out a Purchase Order form and
attach it to the Expense Report form and submit to the City Treasurer.
• The City Treasurer will review the Purchase Order and Expense Report form to assure
original signatures and verify mileage accuracy via Google Maps. Once approved, the
City Treasurer will sign off and submit to the City Administrator.
• The City Administrator will review the Purchase Order and Expense Report form to
assure original signatures. Once approved, the City Administrator will submit to the
City Comptroller for payment processing.
• The City Comptroller will provide final review for completeness, supporting
documentation, expenses in accordance with policy, and proper levels of approvals
prior to payment.
Meals
To be eligible for a meal reimbursement while traveling on official business, the employee must be
in travel status for more than three (3) hours within the meal time frame and be a distance of at
least 10 miles from headquarters or home, whichever is closer. In the event that meals are included
in a registration fee, no meal allowance should be claimed for that meal. Meal expenses are
reimbursable when procured at a prearranged place such as a hotel or restaurant where a meeting,
conference or training session is held. An itemized receipt is required to obtain reimbursement.
Tips of up to 18% are reimbursable by the City. Alcohol is NOT reimbursable.
Registration Fees
If lodging and/or meals are included in the registration fee, the lodging and meal expense cannot be
claimed for reimbursement. Whenever lodging and/or meals are included in a conference or
registration fee, they must be noted on the Expense Report Form.
Miscellaneous Expenses
Miscellaneous business expenses associated with travel are reimbursable. Individual expense items
MUST be supported by paid itemized receipts. All miscellaneous expenses are reported in the
Expense Reimbursement (For items other than travel expenses to be reimbursed) section the
Expense Report Form and must be explained in the space provided at the bottom of the form with
sufficient information to be verified. Examples of allowable miscellaneous expenses include:
needed work supplies purchased on an emergency basis, taxi fares, business telephone calls, etc.
Miscellaneous expenses do NOT include tips and taxes on meals.
If a receipt is not available, a Missing Receipt Statement must be filled out and signed by the
Department Head prior to submitting to the City Treasurer/City Comptroller. If not approved by
the Department Head, the employee will not receive reimbursement.
Educational Reimbursement
The City shall reimburse the employee for tuition and books required for attending any job related
course or for attending any course required for a job related degree, in the amount not reimbursed
by other agencies, provided the Mayor and the Department Head approve such in advance. The
employee must fill out an Educational Reimbursement form prior to the beginning of the course.
The above requirement would be contingent upon the successful completion of such a course.
Successful completion is obtaining a grade of "C" or higher. The City will also pay the cost for
continuing education to maintain any required license.
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City of Canton
2 N. Main St.
Canton, Illinois 61520
(309)647-0020
PRICE INQUIRY FORM
To: From:
Phone Fax Phone Fax
Contact Person Contact Person
Item Unit Extended
Quantity Number Description Cost Cost
TOTAL PRICE
NOTICE TO VENDOR: Please provide the price information, sign the original and return it to the
sender indicated above. All price quotes must be received by
Signature: Title:
Printed Name: Date:
MISSING RECEIPTSTATEMENT
'Cardholder & Transaction Information '
Cardholder Name: Current Date.
Dept Name: _ 'Transaction Date:
Expense Account: Statement Date:
Vendor Name: IAmount: $
Receipt Attached ~
( No further action needed)
ReceiptLost ~
(Ifthe invoice has been lost, complete description below)
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' Missing Receipt Affidavit ' _ _ '
'I certify that the transaction amount documented above was incurred on behalf of the City of Canton
as a legitimate business expense. The charge complies with the City of Canton's purchasing policy and
authorization limits. This form is submitted as a substitute to the original missing receipt.
Cardholder 5ignature _ _ ' '
(ForAcknowledgement of Affidavit) ' _
THIS SECTION TO BE COMPLETED BY '
DEPARTMENT HEAD ' _ '
Approved By. _ _
(Print) ! !
Signature: ' Date: _
Dept Head .
Signature: . Date: '
One missing statement form per each receipt.
Please save this file as a new excel file for your records. Print this file for signatures after filling out all pertinent data.
' Please be sure to attach all receipts to this fo~m for all expenses.
City of Canton EXPENSE REPORT FORM
• : s~., z-
Name ~ r.'...~,',~, ..F . ; Date:
Trave~ _ _
Date Destina6on Pur ose Miles Meals Lod in Other
$ - S - $ -
Totals. Q~~ ~ _ ~
' ' rolis
Miles Personal Vehicle: o x 0.555 ~
Travel Budget Code: oi-so-aso Travel Expense Total: Q
*Grand Total includes the cost of mileage, meals, lodging, and other travel
expense
Expense Reimbursement (For items other than travel expenses to be reimbursed)
Date Business Pur ose Amount Bud etCode
Tota/ Reimbursement: '
Total Trevel Expense: $ -
Travel Advances Make Check Payable to:
Date Business Pur ose Amount Bud et Code
TotalAdvances S'
_ Total Due Employee $ - '
Employee Signature: Supervisor Signature:
Form #031709
3/09
City of Canton
Cardholder Agreement
The City of Canton credit card is essentially a standard credit card in which the credit liability rests
with the Ciry instead of the individual cardholder. The credit card empowers the cardholder to
purchase goods, services and/or travel on behalf of the City.
I agree to the following regarding my use of the City of Canton Credit Card.
I understand that by signing this agreement it is my responsibility to adhere to policies and procedures
made by the City of Canton. Including, but not limited to the following:
1. I understand by using the City of Canton Credit Card and making financial commitments on
behalf of the City, I will strive to obtain the best value for the City.
2. I will submit a detailed original receipt to my department head immediately after a
purchase, ensuring receipt of purchased goods.
3. I understand that under no circumstances will I use the City of Canton credit card for
personal purchases, either for myself or for others.
4. I understand that should I willfully or negligently violate the terms of this Agreement and
use the City of Canton credit card for personal use or gain that I will reimburse the City for
all incurred char~es and anv fees related to the collection of those charges. Under no
circumstances are reimbursements to be made to Wells Fargo.
5. In reading this agreement, I understand the procedures covered in the Agreement and agree
to abide by them. I understand that my failure to adhere to these procedures constitutes
misuse of City property and may result in cancellation of the City of Canton credit card
and/or possible criminal charges.
6. I have been given a copy of the Credit Card Quick Reference sheet and I understand the
basic requirements for using my City of Canton credit card.
I acknowledge receipt of the City of Canton credit card.
Credit Card Number Expiration Date
Cardholder Name (Print) Cardholder Signature Date
Department
City of Canton
Education Reimbursement Form
Course Approval Instructions: Prior to starting your course, complete this form and turn it into your
Department Head. Please complete a separate form for each course you intend to take. Incomplete
forms will be returned to you for completion.
Emnloyee Information
Name Soc. Sec. No.
Department Work Phone #
Home Address
School Information
Name
Course/Certification/Licensing Information
Course Title
Course Number Credit Hours
Course Starts / / Course Ends / /
T~pe of Course:
_ Graduate
_ Undergraduate
_ On-Line Distance Learning
Seminar/Conference
_ Other (including Certification/Licensing Fees or Exam)
Is this course part of a degree program in which you are enrolled? Please give the name of the degree
and date of expected graduation.
Graduate _ Yes _ No Undergraduate _ Yes _ No
Course Tuition $
Books $ Citv Approval:
Fees, materials, etc. $ Amount to be Paid: $
Total Request $
I hereby certify that the information I have provided on this form is truthful and accurate.
Applicant's Signature Date
Department Head's Signature Date
Mayor's Signature Date
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