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(To be completed only by ContractorsMidders claiming to he a "local Indiana business "pursuant to LC. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "lot Indiana business" refers to any of the following: <br />(I) A buApess whose principal place of business is located in an affected county. <br />(2) A busihVs that pays a majority of its payroll (in dollar volume) to residents of affected counties. <br />(3) A busin s�s that employs residents of affected counties as a majority of its employees. <br />(4) A busineA�hat makes significant capital investments In the affected counties as defined in rules opted by the political <br />subdivision. <br />(5) A business th`�t has a substantial positive economic impact on the affected counties as define by criteria in rules adopted by <br />the political subdivision. <br />An affected county �fers to St. Joseph County, Indiana, or the following counties locat adjacent to St. Joseph County: <br />Elkhart County, Mars 11 County, Starke County and LaPorte County <br />There are the following •ice preferences for supplies purchased from a local Indian business: <br />• 5%for a purchase 4xpected by the purchasing agency to be less t an Ofbl <br />• 3%fora purchase eeted by the purchasing agency to beat least $50,0 but less than $100,000. <br />• 1 %. for a purchase ex cted by the purchasingz azenev to be at least $100 00. <br />Date: <br />Pursuant to I.C. 36-1-12-22, <br />preference for Project <br />South Bend, St. Joseph County, <br />claims a local Indiana business <br />(Project # ) located within the City of <br />❑ The location of the printyplafbsin s is <br />(Address) <br />�] St. Joseph CounThe following cdjacent to St. Joseph County,Indiana: <br />The majority of the busior the 12 months prior to the date of this Bid is to residents of St. <br />Joseph County, Indiana aunty noted above. <br />❑ The majority of the bust ss's employees 1qr the 12 months prior to the date of this Bid are residents of <br />St. Joseph County, In ' na, or the adjacent co my noted above. <br />If the business is deemed V be the apparent lowest, resp nsible, responsive bidder, then it shall provide <br />supporting documentatioX for the 12 month period prior the date of the Bid of (i) the total payroll <br />amount paid to all ern# yees of the business, and (H the to payroll amount paid to employees who are <br />residents of St. Josep County and the adjacent county noted aDqve. <br />WHEN SUM YING SUPPORTING PAYROLL <br />Dated this -_ day of <br />20 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or N Agent <br />Printed Name and Title <br />91 <br />