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(To be completed only by Cotrtractors/Bidders elaitititrg to be a "local lfidianR birsitiess"ptirsuaitt 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 principal place 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),4 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 the following counties located adjacent to St. Joseph County: <br />Elkhart County, Marshall County, Starke County and LaPorte County <br />There are the following price preferences for supplies purchased from a local Indiana business: <br />• 5% for a purchase expected by the purchasing agency to be less than $50, 000 <br />• 3% for a purchase expected by the purchasing agency to beat least $50, 000 but less than $100, 000. <br />• 1 % fora purchase expected by the purchasing agency to be at least $100, 000. <br />Date: 9/19/2018 <br />Pursuant to I.C. 36-1-12-22, HULL LIFT TRUCK INC. claims a local Indiana business preference for Project <br />(Project # ) located within the City of South Bend, St. Joseph <br />County, Indiana. <br />The location of the principal place of business is _28747 OLD US 33 WEST, ELKHART, IN 46516: <br />(Address) <br />❑ St. Joseph County, Indiana <br />X The following county located adjacent to St. Joseph County, Indiana: _ELKHART. <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 />WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, <br />BIDDER SHALL REDACTALL SOCL4L SECURITYNUMBERS. <br />Dated this 19" day of SEPTEMBER , 2018_. <br /><�1ractorlBid er {Firm) <br />60 -Q ( 0 ) XmAu � <br />nature of Contractor/Bidder or Its Agent <br />c�� � f �I I <br />JLf-e L I SO rn , .Dvl'Ta <br />Printed Name and Title <br />4 <br />