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(To be completedonly by Cotitractoo-slBiddeiselaititijig to be a "local Indianabusiness"pursuant to LC. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business " refers to any of thefolloiving: <br />(1) A business whose principalplace 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 inakes significant capital investmen ts in the affected counties as defined in rules adopted by the political <br />subdivision. <br />(5) A business that has a substantialpositive economic inipact 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,.1ndiana, or thefolloiving counties located adjacent to St, Joseph County: <br />ElIchart County, Mai -shall Coun tj� Starke County and LaPorte County <br />There are thefolloiving 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 apurchase expected by thepurchasing agency to beat least $50,000 but less than $100,000. <br />• I %for a purchase expected by the purchasing agency to beat least $100, 000. <br />Date: 4 —a � li� <br />Pursuant to I.C. 36-1-12-22, (ATe�,- �-Rv--V-( Wor-co claims a local Indiana business <br />preference for Project (Project # located within the City of <br />South Bend, St. Joseph County, Indiana. <br />The location of the principal place of business is 63 1* mstiftw4tiq �-Aj It'-S-Vs— <br />(4ddress) <br />1J, St. Joseph County, Indiana <br />F-1 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 />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 />WHEN SUPPL YING SUPPORTING PA YROLL RECORDS, BIDDER SHALL REDA CT ALL <br />SOCIAL SECURITYNUMBERS. <br />Dated this D3 day of A-f A � U 20 (S <br />tq- ,—I (E- S C,� (do PC C� <br />Contractor/Bid�e�� <br />Signature 6� Montra'ctor/BlUder or Its Agent <br />,� �( R Lt ^J 0 P 0 u r j--(f t-'T al RIjIll 6 t C <br />Printed Name and Title <br />