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(To be do)ppleted only by Contractors/Bidders claiming to be a "local Indiana business" pursuant to I.C. 36-1-12-22) <br />A "local Indiana bust ess" <br />(1) A business whose in <br />(2) A business that pays <br />(3) A business that emplo <br />(4) A business that makes <br />political subdivision. <br />(5) A business that has a <br />adopted by the political su <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />refers to any of the following: <br />;ipal place of business is located in an affected county. <br />majority of its payroll (in dollar volume) to residents of affected c unties. <br />s residents of affected counties as a majority of its employees. <br />s gnificant capital investments in the affected counties as deli ed in rules adopted by the <br />An `affected county" refers to St. <br />County: Elkhart County, Marshall <br />positive economic impact on the affected <br />County, Indiana, or the following <br />Starke County and LaPorte Cot <br />There are the following price preference for supplies purchased from a <br />• 5% for a purchase expected by the Xurchasing agency to be les <br />• 3% for a purchase expected by the p4rchasing agency to be a e <br />Date: <br />Pursuant to I.C. 36-1-12-22, <br />preference for Project <br />South Bend, St. Joseph County, <br />Indiana. <br />The location of the principal place of <br />❑ St. Joseph County, li <br />as defined by criteria in rules <br />located adjacent to St. Joseph <br />Indiana business: <br />$50,000 <br />50, 000 but less than $100, 000. <br />claims a local Indiana business <br />(Project # ) located within the City of <br />❑ The following county locq(ed adjacent to St.Xoseph County, Indiana: <br />❑ The majority of the business' ayroll for the 12 mont prior to the date of this Bid is to residents of St. <br />Joseph County, Indiana or t adjacent county noted ab e. <br />❑ The majority of the busine s's employees for the 12 month rior to the date of this Bid are residents of St. <br />Joseph County, Indiana r the adjacent county noted above. <br />If the business is deemed to the apparent lowest, responsible, resp nsive bidder, then it shall provide <br />supporting documentation fo the 12 month period prior to the date of the id of (i) the total payroll amount <br />paid to all employees of th usiness, and (ii) the total payroll amount paid employees who are residents <br />of St. Joseph County an he adjacent county noted above. <br />SUPPLYING SUPPORTING PAYROLL Rf <br />Dated this day of \ 20_. <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />Yer. 13 — 6101115 <br />