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Mo be completed only by Con tractors/Bldders clalming to be a-lacallndlana business"pursuant to I C. 36-142.22) <br />12U,.NA LOCAL FUSINESS_ PREFERENCE CLAIM <br />4 "taco! Indiana business" refers to any of the following: <br />(1) A business whose principal place of business is located in an affected county. <br />(2) A business thatpays a majority of its payroll.(in dollar volume) to residents of affected counties. <br />(3) A,buslness that ernpkyt. rsta'etnlr o,ecii� counties a�a: <br />subdivision. a irnr',ry of its epaes: <br />(4) A business that. s gt j'Itt <br />:iifal j tments:l»t1k9. ' d caun# *p 'ned in rules adopted by the political <br />(5) A business that has a substantial posltive economic Impact on the affected counties as defined by criteria in rules adapted by 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 far supplies purchased from a local Indiana business: <br />5% for a purchase expected by the purchasing agency to be kU 1han $50, 000 <br />• 1 %fora purchase expected by the purchasing agency to be at.least $30, 000 but less than $100,000. <br />Date:. ®-."_.. -----� <br />Pursuant to I.C. 36-1.12-22, : � a,,, <br />x claims a local Indiana business <br />preference for Project . SEC (Protect # located within the City of <br />South Bend, St. Joseph County, Indiana. <br />gr 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 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 alcove. <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 />OWN SUM YINGSUPPORT17VGPAYROLL RECORDS, <br />Dated this //Q 0-k &y of Sedjes o <br />N e-of Contra idder or Its Agent <br />�r ,J 94WAi/ nC^ <br />Name and <br />