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(To be completed only byContractorsBiciders claiming tobea"local Indiana business' pursuantioLC.36-1-12-22) <br />A EUCAL 13 UJIN ESS YREN'E-REN C E CLAIM <br />A "local Indiana business" refers to any of the following: <br />(I) A business whose principal place of business is located in an affected county. <br />(2) A business that pays a majority of its payroll (in dollar volume) to residents of affected counties. <br />(3) A business that employs residents of affected counties as a majority of its employees. <br />(4) A business that makes significant capital investments in the affected counties as defined in rules adopted by the political <br />subdivision. <br />(5) A business that has asubstantial positive economic impact on the affected counties as defined by criteria in rules adopted by <br />the political subdivision. <br />An " affected county" refers to St. Joseph County, I ndiana, or the following counties located adjacent to St. Joseph County: <br />Elkhart County, Marshall County, Starke County and LaPorte County <br />There are the following price preferences for supplies purchased from a local Indiana business: <br />• 5%for a purchase expected by the purchasing agency to be less than ur50, 000 <br />• 3% for a purchase expected by the purchasing agency to beat least $50,000 but less than $100.000. <br />• 1 % for a purchase expected by the purchasing agency to beat least $100,000, <br />Date: 1-1 O-Zo 11 <br />Pursuant to T.C. 36-1-12-22, p w,P.(,'1S 1'yt� claims a local Indiana business <br />preference for Project o_ C e r u s) k l ^fl 0- e.(w(dzrcject # ) located within the City of <br />South Bend, St. Joseph County, Indiana. <br />IM The location of the principal place of business is Z I j 5 ero:" ' e r4u r� :1 <br />L16.31� <br />❑ St. Joseph County, Indiana (� 1 <br />PThe following county located adjacent to St. Joseph County, Indiana: rc,t-COr \Q <br />❑ The majority of the business's payroll for the 12 months prior to the date of this Bid is to residents of St. <br />Joseph County, Indiana or the adjacent county noted above. <br />❑ The majority of the business's employees for the 12 months prior to the date of this Bid are residents of <br />St. Joseph County, Indiana, or the adjacent county noted above. <br />if the business is deemed to be the apparent lowest, responsible, responsive bidder, then it shall provide <br />supporting documentation for the 12 month period prior to the date of the Bid of (i) the total payroll <br />amount paid to all employees of the business, and (ii) the total payroll amount paid to employees who are <br />residents of St. Joseph County and the adjacent county noted above. <br />WHEN SUPPL YING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCIAL SECURITYNUMBERS <br />Dated this day of 4^V&,r 20 I 1 <br />O <br />cl( E. e A I Nl <br />Firm) <br />t <br />actor/ idder or Its Agent <br />\oi.._. Sa1eS <br />Title <br />