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(To be completed only by ContractorsBidders claiming to be a "local Indiana business" pursuant to LC. 36-I-12-22) <br />IliDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business"refers to any of the following. <br />(])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),4 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) A 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 following counties located adjacent to St. Joseph County; <br />Elkhart County, Marshall County), Starke County and LaPorte County <br />There are the following price preferences for supplies pur-chased from 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 />• I % for a purchase expected by the purchasing agency to be at least $100, 000. 9 <br />Date: )0 t b 120 ►1 f- `_ <br />Pursuant to T.C. 36-1-12-22, 1 1C�1��v-, Guy &I(WtZk r)-'Yxc— claims a local Indiana business <br />preference for Project 5 CC NN (Project # ) located within the City of <br />South Bend, St. Joseph County, Indiana. <br />❑ The location of the principal place of business is 210,5 N. M Gk" Z aO 5+) i1i0A:)--tJJ <br />OmssJ <br />❑ St. Joseph County, Indiana ` t <br />Ix The following county located adjacent to St. Joseph County, Indiana: N (5h1 11 <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 />SOML SECURITY NUMBERS. <br />Dated this day of 120 I <br />� [ <br />f� ',6A : c��nfi21 <br />MaAyi CGUKI+ Cheilolei -11-n c. ' <br />Contractor/Bidder (Finn) <br />s <br />,--m�ature o ontractorBidder or Its Agent <br />v�/11�11 mQ"ni ! rC°SI de <br />Printed Nance and Title <br />0 <br />