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(Ta be completed only by ContractorslBidders claiming to be a "local Indiana business"pursuant to 1_t7. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A 'local Indiana business"refers to any of the following: <br />(1) it bacsinr:,ss whose principal place of business is located in an affected county. <br />( ) A business drat p(ys a rnajorily of its payroll (in dollar volume) to residents of affected counties. <br />(�) A business that employs residents of affected counties as a majority of its employees. <br />(4) A brrsince s that makes significant capital investments in the affected counties as defined in males adopted ht the pnliticrrl <br />svhdavSlon- <br />(5) A baShicss that has a substantlalpositive economic impact on the affected counties as defined b)' crlleria in r riles ad)plerl h)- <br />Me political subdivision. <br />Aa "rrfected couno)" refers to St. Joseph County, Indiana, or the following counties located adjacent to ,31. doseph CoarnN. <br />1 lkhmvt County, Marshall County, Starke County and LaPorte County <br />Acre are the ji�Ilowing price preferences for supplies purchased, from a local Indiana business: <br />s Q for ca pan•clrase expected by the pua'chasuzg agency to be less than $50,000 <br />3i'o fur• a purchase expected by the purchasing agency to beat least $50,000 but less than $100,000. <br />1 ` �, lbf- a purchase expected by the purchasin-v akenev to beat least $100.000. <br />f,,,ti;,, 06 11 18 <br />Pursm,jA it) i.C. 36-1-12-22, <br />preference for Project <br />South Bend, St. Joseph County, Indiana. <br />�Y] The location of the principal place of business is <br />clairris a loc: d Iiwlana bu�-,10 c"N <br />(Project # ) located %vidlin 11w {-;ity oi' <br />919 Nr <br />eR44-9/ OLIVE ST <br />tA<td,V—) <br />X St. Joseph County, Indiana <br />EJ 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 S1. <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. oi' <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 />ainonnt paid to all employees of the business, and (ii) the total payroll amount paid to employees who rani <br />residents of St. Joseph County and the adjacent county noted above. <br />l< HEN SUM FING SUPPORTING PAYROLL RECORDS, BIDDER SHALL, REIMC'T AI L <br />SOCIAL SECURITY NUMBERS. <br />Dated this _ day of , 20 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />