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(To be conipleted only by ContractorslBidders clahning to be a "local Indiana business"pursuallt to LC 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business " refers to an), of thefolloiving: <br />(])A business xhose principalplace of business is located ill all affected county. <br />(2) A business that pays a inajority of its pqyroll (in dollar voluine) to residents of affected counties. <br />(3) A business that eniploys residents of affected counties as a majority of its einployees. <br />(4),4 business that inakes significant capital investments in the affected counties as defined in rules adopted by the political <br />subdivision. <br />(5),4 business that has a substantial positive econoinic inspact oil the affected counties as defined by criteria ill rules adoptedby <br />the political subdivision. <br />,4n "affected counly "refe)-s to St. Joseph Couno� Indiana, or thefollowing counties located adjacent to St. Joseph County <br />Elkhart Coun rj� Marshall Countj� Starke Couno, and LaPorte Couno, <br />There are thefollou,ing price preferencesfor suppliespurchasedfroin a local Indiana business: <br />• 5%for apurchase expected by thepurchasing agency to be less than $50,000 <br />• 3%for apurchase expected by thepurchasingagency to beat least $50,000 but less than $100,000. <br />• 1%for apurchase expected by the purchasing a ency to beat least $100,000. <br />Date: C� a � % <br />Pursuant to I.C. 36-1-12-22, LATES CKW-1 Wt,(ZLO claims a local Indiana business <br />preference for Project S PE C 14 Alulf�t&�- TftlA'SoOkl- _(Project# ....... . ) located within the City of <br />South Bend, St. Joseph County, Indiana. <br />91 The location of the principal place of business is <br />Y <br />(AdWrmsJ <br />Vg- St. Joseph County, Indiana <br />F-1 The following county located adjacent to St. Joseph County, Indiana: <br />f-A The majority of the business's payroll for the 12 months prior to the date of this Bid is to residents of St. <br />Lf- <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 deemed 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 />WHENSUPPL YING SUPPORTING PA FROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCIAL SECURITYNUMBERS. <br />Dated this day ofA- P 04 C- _, 20 1 �) <br />C F� —( S (- �A e LPY Q 0 <br />C ontractqPBMZle-rTRr-qi) <br />- C—f --5� <br />Signature of Contractor/Bidder or Its Agent <br />5k,4ck,�-) <br />Printed Name and Title <br />8 <br />