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NOT APPLICABLE <br />(To be completed only by Contractors/Bidders claiming to be a "local Indiana business" pursuant to I.C. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <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 lins <br />(3) A 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 defineed by the <br />political subdivision.(5) A business that has a substantial positive economic impact on the affected counties asria in rules <br />adopted by the political subdivision. <br />An "affected county" refers to St. Joseph County, Indiana, or the following/0,000 <br />ed adjacent to St. Joseph <br />County: Elkhart County, Marshall County, Starke County and LaPorte Co <br />There are the following price preferences for supplies purchased from a lsiness: <br />• 5% for a purchase expected by the purchasing agency to be less th3% for a purchase expected by the purchasing agency to beat lealess than $100, 000. <br />• 1% for a purchase expected by the purchasing agency to beat leas <br />Date: <br />Pursuant to I.C. 36-1-12-22, <br />preference for Project <br />South Bend, St. Joseph County, Indiana. <br />The location of the principal place of business <br />❑ St. Joseph County, Indiana <br />❑ The following county located <br />The majority of the business's payro <br />Joseph County, Indiana or the adjv <br />' claims a local Indiana business <br />(Project # ) located within the City of <br />(Address) <br />to St. Joseph County, Indiana: <br />for the 12 months prior to the date of this Bid is to residents of St. <br />t county noted above. <br />❑ The majority of the business's a ployees for the 12 months prior to the date of this Bid are residents of St. <br />Joseph County, Indi/hess, <br />adjacent county noted above. <br />If the business is deemed tparent lowest, responsible, responsive bidder, then it shall provide <br />supporting documentation foonth period prior to the date of the Bid of (i) the total payroll amount <br />paid to all employees of the nd (ii) the total payroll amount paid to employees who are residents <br />of St. Joseph County and thcounty noted above. <br />SUPPLYING SUPPORTING PAYROLL RECORDS, <br />Dated this day of , 20_ <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />