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(To be completed only by ContraclorsIBIdders claiming to be a "local Indiana business"pursuant to LC 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business "refers to any of thefollowing" <br />(1) A business whose principalplace of business is located in an affected county. <br />(2) A business that pays a majority of its payroll (in dollar volume) to residents of affected counties. <br />(3) A business that employs residents of affected counties as a majority of its employees. <br />(4) A business that makes significant capital investments in the affected counties as defined in rules adopted by the political <br />subdivision. <br />(5) A business that has, a substantial positive economic impact on the affected counties as defined by criteria in rules adopted by <br />the political subdivision. <br />An "affected county " refers to St. Joseph County, Indiana, or thefollowing counties located adjacent to St. Joseph Coun�ty: <br />Elkhart County, Marshall County, Starke County and LaPorte County <br />There are thefollowing price preferencesfor supplies purchasedftom a local Indiana business: <br />* 5%for apurchase expected by the purchasing agency to be less than $50,0�00 <br />* 3 %for a purchase expected by the purchasing agencyto beat least $50, 000 but less than$] 00, OW <br />* ]%for a purchase expected by the purchasing agency to beat least $100, 000. <br />Date: <br />Pursuant to I.C. 36-1-12-22, &Iu �;Lrv;'Ce� r. (-4,C claims a local Indiana business <br />preference for Project Axowd (Proiect located within the City of <br />South Bend, St. Joseph County, Indiana. � I <br />J2 , <br />The location of the principal place of business is �&rPU)� Z4,4- 2 /3 1114'11,119,GIV -7W 061411/6 <br />(Addreds) ( I <br />F-] 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 />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) 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 />WHENSUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCL4L SECURITYNUMBERS. <br />Dated this day of4t,, �c,-4 20_L2!— <br />Go.utractor/Bidd <br />er (F-r!n) <br />S7'natLu,e -6f C-,o,, ractor/13 idder or Its Agent <br />t A,4 % <br />s/ , &q <br />Printed Name and Title' <br />on <br />