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-actorsl -s clahn ing to be a "local Indiana business "purstiant to L C 3 6-1-12-22) <br />(To be coinlVeted only by Conn BUM <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />Da te: <br />Pursuant to I.C. 36-1-12-22, (IAVC�> �—Rfzvq 00"--L� claims a local Indiana business <br />preference for Project t-A (0 - S (2-C rotAA— Opt,(g, 4(4 9911) (Project # PEC P located within the City of <br />South Bend, St. Joseph County, Indiana, <br />The location of the principal place of business is ks. mapoa Atc— m i sF(Aww <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 />-ior to the date of this Bid are residents of <br />The majority of the business's employees for the 12 months pi <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 SUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this *3 day of A-q--,20 <br />A -'I 6 <br />Contractor der -m) <br />SignatLIN Or COntraCtOF/Bidder or Its Agent <br />Printed Name and Title <br />