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(To be completed only by Contractors/Bidders elaisiing to be a "local Indiana business"pursuant to I.C. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE 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),4 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 foiloiving counties located adjacent to St. Joseph County: <br />Elkhart County, Marshall County, Starke County and LaPorte County <br />There are the followirzg price preferences for° supplies purchased fronh 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 />• 1 %. for a purchase expected by the purchasing agency 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 />N /H <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 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 SUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACT ALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this day of , 20 <br />Contractor/Bidder (firm) <br />Signature of ConLractorlBidder or Its Agent <br />Printed Name and Title <br />