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('robe completed only by Contractors/6ldders claiming to be a "local Indiana business" pursuant to I.C. 36-1-12-221 <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 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 <br />political subdivision. <br />(5) A business that has a substantial positive economic impact on the affected counties as defined by criteria in rules <br />adopted by the political subdivision. <br />An "affected county" refers to St. Joseph County, fndiana, or the following counties located adjacent to St Joseph <br />County: 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 $60,000 <br />• 3% for a purchase expected by the purchasing agency to beat least $50, 000 but less than $100, 000. <br />- 1 % fora purchase ex eec""ted b 0, the purchasing a ency to beat least $10000. <br />Date: A IA Q W 5+ __ D /a C.7 7 <br />Pursuant to I.C. 36-1-12-22, claims a local Indiana business <br />preference for Project (Proje t # ) located within the City of <br />South Bend, St. Joseph County, Indiana. <br />Cl 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 St. <br />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 amount <br />paid to all employees of the business, and (ii) the total payroll amount paid to employees who are residents <br />of St. Joseph County and the adjacent county noted above. <br />WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, <br />BIDDER SHALL REDACT ALL SOCIAL SECURITY NUMBERS: <br />Dated this.day of, 20 / 1 <br />L✓ <br />Contracto /Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />-M <br />Printed Name and Title <br />