Agenda Item Summary

Anyone wishing to be placed on the Agenda must complete this form and return it to the City Office, 106 N. 2^nd, Sargent NE by Noon on Friday prior to the City Council Meeting.

Name:_______________________________________

Address:_____________________________________

Phone #:_____________________________________

For the Meeting of :____________________________

Agenda Item Title:_________________________________________________________

Clearly State Your Comment or Concern: ____________________________________________________________

____________________________________________________________________________________________

State what Action you would like taken:______________________________________________________________

____________________________________________________________________________________________

Does this item require expenditures of funds:__________ Yes ______________ No

Was this item addressed in the budget? __________ Yes _____________ No

(For City Use)

Date Submitted:__________________

Action Taken:___________________________________________________________________________________

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