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Oct. 28, 2016 1:37PM No, 1543 P. 5/8 (robe completed ohly by Contractors/aidders claiming to be a "local Indiana business"pursuant to I.C. 36-1-12.22) INDIANA LOCAL BUSINESS PREFERENCE CLAIM A 'vocal Indiana business" refers to any of the following: (1) A business whose principal place of business is located in an affected county. (2) A business that pays a majority of its payroll (in dollar volume) to residents of affected counties. (3) A business that employs residents of affected counties as a majority of Its employees. (4) A business that makes significant capital investments in the affected counties as defined in rules adopted by the political Subdivision. (5) A business that has a substantial positive economic impact on the affected counties as defined by criteria in rules adopted by the political subdivision. An `affected county" refers to St. Joseph County, Indiana, or the following counties located adjacent to St; Joseph County. Elkhart County, Marshall County, Starke County and LaPorte County There are the following price preferences for supplies purchased from a local Indiana business, 5% for a purchase expected by the purchasing agency to be less than $50, 000 3%for a purchase expected by the purchasing agency to beat least $50,000 but less than $100,000, 1 % for a purchase expected by the purchasin agency to beat least $100,000.. Date: f U /a r��.i . Pursuant to I.C. 36.1-12- 2, Cb�;dmcn+claims a local Indiana business preference for Project �D bTV rc (Project # ) located within the City of South Bend, St. Joseph ounty, Indiana. n L / �g The location of the principal place of business is dl t 't. S •1 awe k r d. F�K(G r TAB 9 (ada(ess) ❑ St. Joseph County, Indiana l/ The fqollowing County located adjacent to St, Joseph County, Indiana: �� tar (f/ �( The majority of the business's payroll for the 12 months prior to the date of this Bid is t residents of St. \/ Joseph County, Indiana or the adjacent county noted above. qt The majority of the business's employees for the 12 months prior to the date of this Bid are residents of St. / Joseph County, Indiana, or the adjacent county noted above. If the business is deemed to be the apparent lowest, responsible, responsive bidder, then it shall provide supporting documentation for the 12 month period prior to the date of the Bid of (i) the total payroll amount paid to all employees of the business, and (it) the total payroll amount paid to employees who are residents of St. Joseph County and the adjacent county noted above. WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACT ALL SOCIAL SECURITY NUMBERS Dated this day of , 20A . A, t NGrTAWl Printed ame and T" Is Version 8 — 02/25%14