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(To be completedonly by ContractoWBidderselohning to be a "local Indiana business"pursuant to LC. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business" refers to any of thefollowing: <br />(1) A business whoseprincipalplace of business is located in all affected county. <br />(2) A business.that pays a majority of its payroll (in dollar volume) to residents ofaffected counties. <br />(3) A business that eniploys residents ofaffected counties as � nullority of its eniployees. <br />(4) A business that nulkes significant capital investnients in the affected counties as defined in rules adopted by thepolitical <br />subdivision. <br />(5) A business that has a substantialpositive econondc inipact on the affected counties as defined by criteria in rules adopted by <br />thepolffical subdivision. <br />Ali "affected county " refers to St. Joseph County, Indiana, or thefollowing counties located adjacent to St. Joseph County. - <br />Elkhart County, Marshall County, Starke County andLaPortle County <br />Aere are thefollowing price preferencesfor supplies purchasedfroin a local Indiana business: <br />• 5%for apurchase expected by thepurchasing agency:to be less than $50,000 <br />• 3%for a purchase expected by thepurchasing agency: to beat least $50, 000 but less than $100, 000. <br />I <br />• ]%fior a purchase expected by the purchasing agency to be at 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 />(Project # ..) located within the City of <br />E] The location of the principal place of business is <br />(4ddress) <br />El St. Joseph County, Indiana <br />0 The following county located adjacent to St. Joseph County, Indiana: <br />E] 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 deerned to be the apparent lowest, responsible, responsive bidder, then it sball 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 SUPPL YING SUPPORTING PA YROLL RECORDS, BIDDER SHALL REDA CT ALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this day of 20 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />