Opening of Bids - Eight Cardiac Monitors Defibrillators - Physio-Control, Inc. - Part 1

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(To be completedonly hy Coiiti°tictoisIBi(Ititrselaiiiiiiig t© be a "local liotliait(tbti.viiievs"piti,,viiarit to LC 36-1-12-22) INDIANA LOCAL BUSINESS PREFERENCE CLAIM A "local Indiana business " ref ers to any of thefillolving: (])A business uhose principal place of business is located in an f q.fected county, (2) A business that pays a majority of its payroll (in dollar volume) to residents of affected counties. (3) A business that employs residents qf affected counties as a majority of'its employees. (4) A business that makes significant capital investments in the effected counties as dqfrned in rules adopted by the political subdivision (5) A business that has a substantial positive economic impact on the aff ected counties as defined by criteria in rules adapted by the political subdivision. An "ql .fected county" refers to St. Joseph County, Indiana, or the folloiving counties located adjacent to St. Joseph County P,Wkharl (,ounljr, Marshall County, Starke County and LaPorte County There are the.161losvingpi-ice preferences for supplies purchasedfiroin a local Indiana business: • 5%for a purchase expected by the purchasing agency to be less than $50,000 • 3%fior a purchase expected by the purchasing agency to be at least $50,000 but less than $'100,000, • I %fior a purchase expected by the purchasing agency to be at least $100, 000. Date: No I A pphcable, Physio-Con I ro I, Inca, is 11 ot a loca I bi Is iness in I I w, Slat c ('41ndiana, Pursuant to I.C. 5-22-15-20.9, preference for Project South Bend, St, Joseph County, Indiana. F-1 The location of the principal place of business is claims a local Indiana business (Project # ) located within the City of (Addl-0,u) E] St. Joseph County, Indiana F-1 The following county located adjacent to St. Joseph County, Indiana: ❑ The majority of the business's payroll for the 12 months prior to the date of this Bid is to residents of St. Joseph County, Indiana or the adjacent county noted above. The majority of the business's employees for the 12 months prior to the date of this Bid are residents of St. Joseph County, Indiana, or the adjacent county noted above. If the business is deemed to be the apparent lowest, responsible, responsive bidder, then it shall provide supporting documentation for the 12 month period prior to the date of the Bid of (i) the total payroll amount paid to all employees of the business, and (ii) the total payroll amount paid to employees who are residents of St. Joseph County and the adjacent county noted above. WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL SOCIAL SECURITYNUMBERS. Dated this day of 20 Contractor/Bidder (Firm) Signature of Contractor/Bidder or Its Agent Printed Name and Title