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(To beconipletedonlyby Catiti-acte�evlBiddepvcfaitiiitig to be a 111ocalIndiana business"pursuant to LC. 36-1-12-22) <br />YNY)TANA 1,0CAT, RINI NESS PREFERE NCE CLAIM <br />A "local Indiana business " refer's to any of thefollowing: <br />(])A business whoseprincipal place of business is located in an afftctedcounty, <br />())A business that pays a inajority (if itspayroll (In dollar voluine) to residents of affected counlies� <br />(3) A business that einplo s rt�yldenis qf etjl4ted counties as a nuyority of its eniployees. <br />(4) A business thatniokf.�s siquifiWail calWal investinents in the (it <br />-fi!cied counfies as d(fined in rules adopted bythe political <br />subdivWon. <br />(5) A business that has a substantialpositive econoinic iinpact on the affected counties, as defined by criteria in rules adoptedby <br />the political subdivision. <br />A n "qf e h t <br />,fected county " rq <br />fiers to St, Joseph Cotenty, Indiana, or thefollovving counties located adjacent to St. - osp Coun y: <br />Elkhart County, Alai -shall County, Starke County and LaPorte Count), <br />7'11ere are thefollowing price preferencesfor suppliespurchzedfroni a local Indiana business: <br />- Blofor a purchase expected by the purchasing agency to be less, that $50,000 <br />- 3%for apurehase expected by thepurchasingagency to be at least $50,000 but less than $100,000, <br />Date: 1 11 <br />Pursuant to I.C. 36-1-12-2 claims a local Indiana business <br />preference for Project V&-C-, N- -oject # located within the City of <br />South Bend, St, Joseph County, Indiana, <br />Eir The location of the principal place of business is A -_�) �2 <br />�-� �,(V <br />qz3- M <br />St, Joseph County, Indiana <br />F� The following county located adjacent to St. Joseph County, India= <br />f-1 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 />El 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) tile total payroll <br />amount paid to all employees of the business, and (ii) the total payroll arnount paid to employees who are <br />residents of St, Joseph County and the adjacent county noted above. <br />W11ENSU1>P1,y1NG SUPPORTING PAYROLL RECORDS, BIDDER SHAY, REDACTALL, <br />soaw, <br />Dated this day of. <br />4-Cl— — — � A� <br />�?Ure�-;�IcFontr'a� idder or Its Agent <br />Al <br />Printed Name and Title <br />