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(To be completed only by ContractorsMidelers claiming to be a "local Indiana business"pursuant to LC 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />. .. . . ..... . . ............ ..... . .... ... .. ..... ... .. ........ .... ... ... <br />A "local Indiana business " n7fers to cv�v qf theJ611olling: <br />(/)A business. whose principal place qf,blishless is located in fill qfl�-cted cololN, <br />(2) A business that pays a wqjorio�qfitspqyroll (ill dollar voltime) to residents qfqff 11 s <br />ected com ie <br />(3) A business that employs residews of q&cted coanties as a majority oj'ifs employees. <br />-ides adopted by the political <br />(4) A b[1Sil7e$S that. makes signYicant capital iniestinents in the qf <br />fecled corinties as dqfined in i <br />siibdivision, <br />economic impact oil the q1 d counties as d�fbied by criteria ill olles adopted by <br />(5) Abusiness that has a substantialpositivt J�ctc <br />the political subdivision. <br />An cown),, re�ffi-s to St. Joseph County, Indiana, or the.1611owing counties located adjacent to St. Joseph Colfn�: <br />*e Counly and LaPo le Colalo� <br />Elkhart Cou. 16,, Marshall Couno), Sla) I <br />There are tl?ejblloivii7gpi-icept-o�reiic(,s,lbi- supplies purchasedfi-on? a local Indiana business: <br />5%for a purchase expected by thepurchasingagencY to be less thall $50,000 <br />3% or a purchase expected bv tile purchasing agency to be at least S50, 000 but less than $100, 000. <br />fi <br />I % for a purchase Lx2ected!�, th e pinvhashig agenc�v to be (it least S100, 000, <br />Date: <br />-S T lu TA <br />Pursuant. to. I.C. 36-1-12-22, c4TC 011 claims a local Indiana business <br />preference for Project /k 11) - S(n-� C f uv�k- D00 (L AA469( (Project # �PfC- located within the City of <br />South Bend, St. Joseph County, Indiana. <br />�qo f(Av j) p t) Ytklcl <br />The location of the principal place of business is <br />St, Joseph County, Indiana <br />The following county located adjacent to St. Joseph County, Indiana: <br />The majority of the business's payrol I 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 tile 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, HIDDE, R SHALL REDA CT ALL <br />SOCIAL SECURITY NUMBERS. <br />Dated th is day of 20 <br />T <br />To <br />ContracItpihl �tder (Firmy-) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />