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(To be coinpleted only by ConhwctorslBidders clahning to be a "local Indiana business"pursuant to L C. 36-1-12-22) <br />INDIANA LOCAL BUNINENS <br />UE ULAIM <br />A "local Indiana business "refers to any of thefollo�ving: <br />(1) A business �vhose principalplace of business is located in all affected county. <br />(2) A business thatpays a inajority of its payroll (ill dollar volunje) to residents of affected counties. <br />(3) A business that eniploys residents ofaffected counties as a nlajority of its elliployees. <br />(4) A business that niakes significant capital investinents in the affected counties as defined in rifles adopted by the political <br />subdivision, <br />(5) A business that has a substantial positive econondc inipact oil the affected counties as defined by criteria in rifles adopted by <br />the political subdivision. <br />An "affected county" refers to St. Joseph County, Indiana, or thefbllo�ving counties located adjacent to St. Joseph County: <br />Elkhart County, Marshall County, Starke County andLaPort,e County <br />7here are thefollowingpricepreferences for supplies purchasedfroni a local Indiana business: <br />. 5%for a purchase expected by the purchasing agency: to be less than $50, 000 <br />. 301ofor a purchase expected by the purchasing qgenqy� to beat least $50, 000 but less than $100, 000� <br />- ]%fior a purchase expected by thepurchasing agency �o beat least $100,000. <br />Date: <br />Pursuant to I.C. 36-1-12-22, <br />preference for Project <br />South Bend, St, Joseph County, Indiana. <br />claims a local Indiana business <br />(Proj ect # ) located within the City of <br />The location of the principal place of business is <br />(Address) <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 />r] 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 deerned 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 />WHENSUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this _ day of 2 20 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />