Opening of Bids - Spec AK - Two More or Less 2018 or Newer 18,000lb Four Wheel Drive Chassis with Dump Beds - Lake Shore Ford Part 1

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(To be completed only b Contractors/Bidders claiming to be a "local Indiana business" pursuant to LC. 36-1-12-22) IND NA LOCAL BUSINESS PREFERENCE CLAIM A "local Indiana business" r fers to any of the following: (I) A business whose princi al place of business is located in an affected county. (2) A business that pays am jority of its payroll (in dollar volume) to residents of affected counties. (3) A business that employs esidents of affected counties as a majority of its employees. (4) A business that makes si nificant capital investments in the affected counties as defined in rules adopted by the political subdivision. (5) A business that has a sub tantlal positive economic impact on the affected counties as defined by criteria in rules adopted by the political subdivision. An "affected county" refers to St. Joseph County, Indiana, or the following counties located adjacent to St. Joseph County: Elkhart County, Marshall County, Starke County and LaPorte County There are the following pric preferences for supplies purchased from a local Indiana business: • 5% for a purchase 4exected by the purchasing agency to be less than $50, 000 • 3%for a purchase ected by the purchasing agency to be at least $S0 000 but less than $100, 000. • 1 °10 or a urchase ex cted b the urchasin agencyto be at least $1OQ000. Date: 1,,L ` Pursuant to I.C. 36-1-12 22, _ claims a local Indiana business preference for Project (Project # _ } located within the City of South Bend, St. Joseph County, Indiana. ❑ The location f the principal place of business is M6a TMA Pd- G viis gt- -T J ❑ St. Jc seph County, Indiana ❑ The ollowing county located adjacent to St. Joseph County, Indiana: ❑ The majority of the business's payroll for the 12 months prior to the date of this Bid is to residents of St. Joseph Coun , Indiana or the adjacent county noted above. ❑ The majority of the business's employees for the 12 months prior to the date of this Bid are residents of St. Joseph Co, nty, Indiana, or the adjacent county noted above. If the business is deemed to be the apparent lowest, responsible, responsive bidder, then it shall provide supporting document tion for the 12 month period prior to the date of the Bid of (i) the total payroll amount paid to all employees of the business, and (ii) the total payroll amount paid to employees who are residents of St. Joscp4 County and the adjacent county noted above. WHEN SUPPLrG SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACT ALL SOCIAL SECURITY NUMBERS. Dated this �� day of .20 Contractor/Bidder (Firm) Signature of Contractor/Bidder or Its Agent Printed Name and Title