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(To be completed only by ContractorsIBitl(ler•sclaitttittgto be a `°localIndiana business"pursuant toW, 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business" refers to any of the following.• <br />(])A business whose principal place ofbusiness is located in an affected county, <br />(2) A business that pays a majority of its payroll (in dollar volurne) to residents of ajJected counties. <br />(3) A business that employs residents ofaffected 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 politic al <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 thefollotving counties locatedadjacent to St, Joseph County: <br />Elkhart County, Mat -shall County, Starke County and LaPorte County <br />There are thefollowingprice preferencesfor suppliespurchasedfrom a locallndianabusiness: <br />5910for a purchase expected by the purchasing agency to be lessthan$50,000 <br />• 3 % for a purchase expected by the purchasing agency to be at least $50,000 but less than $100,000. <br />• 1 % for a purchase expected by the purchasing agency to beat least $] 00,000. <br />Date: Z ~7_--;v-7 7 <br />Pursuant to I.C. 36-1-12-22, <br />preference for Project <br />South Bend, St. Joseph County, <br />Indiana. <br />claims a local Indiana business <br />(Project # ) located within the City of <br />The location of the principal place of business is 3o (!,vS ��k r wG��yi/ r A) <br />(Address) i- I Lt <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 REDACTALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this day ofQ, , 20_ <br />D6 COA 0+ -, <br />Contractor ' m) <br />ignature of Contract/Bidder or Its Agent <br />T dl ; �- <br />Ver, 2 — 4/16/12 <br />