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(To be completed only by Contractors/Bidders 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 thefollowing: <br />(])A business whose principal place ofbusinessis located in an affected county. <br />(2) A business thatpays a majority of its payroll (in dollarvolume) to residents of affected counties. <br />(3) A business that employs residents of affected countiesas a majority of its employees. <br />(4) A business that makes significant capital investments in the affected counties as defined in rules adoptedby thepolitical <br />subdivision. <br />(5) A business thathas a substantial positive economic impacton 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 thefollowing counties located adjacent to St. Joseph County: <br />Elkhart County, Marshall County, Starke County and LaPorte County <br />There are the followingpi'ice pr-efer-encesfor suppliespurchasedfr-om a locallndiana business: <br />• 5%for a purchase expected by thepurchasing agency to be less than $50, 000 <br />• 3% for a purchase expected by thepurchasing agency to be at least $50, 000 but less than $ ]00,000. <br />• I%for apurchase expected by thepurchasing agency to heat least$]00,000. <br />Date: 0��� 1�20/`7 <br />Pursuant to I.C. 36-1-12-22 j au e e Cf--wTMSt /N.., Tl��-IC <br />Maims a local Indiana business <br />preference for ProjectSlNl -r— k7lLE- tf 1¢ GINi /fc° P_ (Project16f— � }locatedwithin the City of <br />South Bend, St. Joseph County, Indiana. <br />The location of the principal place of business is 5&(, ITY �'�I D, /IJ *6 <br />(Address) <br />X St. Joseph County, Indiana <br />❑ The following county located adjacent to St. Joseph County, Indiana: <br />YN 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 SUPPL YING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCIAL SECURITYNUMBERS. <br />S/4 <br />Dated this `� day of �s�%FMi�' , 20 i <br />iN <br />Contr tor/Bidder (Firm) <br />a i a e of C o ra /Bder or Its Agent <br />gle-14 SK-/ <br />Printed Name and Title ? <br />�A'i 0,5 Y-9—ZrtTl VG� <br />8 <br />