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(To be completed only by ContractorslQuoters clahning to be a "local Indiana business'* pursuant to LC. 36-1-12-22) <br />A "local Indiana business" refers to any of the following: <br />(1) 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) A business that employs residents of affected counties as a majority of its employees, <br />(4) A business that makes signcant capital investments in the af <br />fected 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, Mat -shall County, Starke County and LaPorte County <br />There are the following price preferences for supplies purchased from a local Indiana business: <br />• 5%,for a purchase expected by the purchasing agency to be less than $50,000 <br />• 3%for apurchase expected by the purchasing agency to beat least $50,000 but less than $100,000. <br />• 1%fora purchase expected ly_ the ing en tobeatleast $700,000. <br />_pmchash _ygen <br />Date: <br />Pursuant to I,C. 36-1-12-22, claims a local Indiana business preference <br />5— <br />for Project (Project # _) located within the City of South Bend, <br />St. Joseph County, Indiana. <br />0 The location of the principal place of business is <br />(Address) <br />El St. Joseph County, Indiana <br />U The following county located adjacent to St. Joseph County, Indiana: <br />El The majority of the business's payroll for the 12 months prior to the date of this Quote is to residents of St. <br />Joseph County, Indiana or the adjacent county noted above. <br />0 The majority of the business's emp,loyces for the 12 months prior to the date of this Quote 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 Quoter, then it shall provide <br />supporting documentation for the 12 month period prior to the date of the Quote 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 S UPPL YING SUPPORTING PA YR OLL RE, CORDS, <br />Dated this day o�f <br />Vi Y el,4) <br />Signatre,qf° ontracto , r/Quoter or Its Agent <br />a " <br />"(1 " <br />Printed Name and Title <br />Ver. 5-- 10122112 <br />