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(To be completed only by Contractorslidders Claiming to be a `local Indiana business"pursuant to LC. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A 'local Indiana business" refers to any of the following: <br />(1) A business whose principal place of business is located in an affected countyIsiness: <br />(2) A business that pays a majority of its payroll (in dollar volume) to residents d counties. <br />(3) A business that employs residents of affected counties as a majority of its em <br />(4) A business that makes significant capital investments in the affected countiesed in rules ado d by the political <br />subdivision. <br />(5) A business that has a substantial positive economic impact on the affected cos defined b criteria in rules adopted by <br />the political subdivision. <br />An "affected county" refers to St. Joseph County, Indiana, or the following counted cent 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 Insiness: <br />• 5%far a purchase expected by the purchasing agency to be less than $50 <br />• 3%for a purchase expected by the purchasing agency to beat least $50,0ss than $100, 000.1% or a urchase ex ected b the ureJzasina a en to be at least $100, <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 busine is <br />tAddr-s) <br />❑ St. Joseph County, Indiana <br />❑ The following county locate adjacent to St. Joseph County, Indiana: <br />❑ The majority of the business's p -oll for the 12 months prior to the date of this Bid is to residents of St. <br />Joseph County, Indiana or the jacent county noted above. <br />❑ The majority of the busine 's employees for the 12 months prior to the date of this Bid are residents of <br />St. Joseph County, India , or the adjacent county noted above. <br />If the business is deemed to the apparent lowest, responsible, responsive bidder, then it shall provide <br />supporting documentation r the 12 month period prior to the date of the Bid of (i) the total payroll <br />amount paid to all employ es of the business, and (ii) the total payroll amount paid to employees who are <br />residents of St. Joseph C unty and the adjacent county noted above. <br />WHENSUPPL� 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 />