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(To be completed only by Contractors/Bidders clahning to be a "local Indiana business"pursuant to I.C. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana bus iness " refers to any of the following: <br />(1) A business ivhose 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 a substantial 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, Indiana, 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 fr•oin a local Indiana business: <br />• 5% for a purchase expected by the purchasing agency to be less than $50, 000 <br />• 3% for a purchase expected by the purchasing agency to beat least $50, 000 but less than $100, 000. <br />• I % or a purchase c ected by the purchasing agencyqgency to be at least $100, 000. <br />Date: <br />Pursuant to I.C. 36-1-12-22, <br />preference for Project <br />South Bend, St. Joseph County, Indiana. <br />claims a local Indiana business <br />(Project # ) located within the City of <br />❑ The location of the principal place of business is <br />(Address) <br />❑ St. Joseph County, Indiana <br />❑ The following county located adjacent to St. Joseph County, Indiana: <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 dou.mcU M b:. tl.c apparent to c—st, rc3ponsihle, 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 />WHENSUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCIAL SECURITYNUMBERS. <br />Dated this day of <br />20 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />