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(To be completed only by Contractors/Bidders claiming to be a "local Indiana business" pursuant to I.C. 36-1-12-22) <br />INDIANA LOCAL RITgINF.CC PIRV1Pr1D Wt-u rT A rnR <br />—•—� — —�: a.: aara vie <i LL 111V1 <br />A "local 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 that pays a majority of its payroll (in dollar volume) to residents of ajjected 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 afPcIed county" refers to St. Joseph County, Indiana„ or thefiollowing counties located adjacent to St. Joseph County: <br />lkhart Count)a, 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 % er+ a ai r c lrcawse ��e °t el he xr c , in a : eni to beat least $100, 000, <br />Date: <br />Pursuant to I.C. 5-22-15-20.9, _.. TES __ .... claims a local Indiana business <br />preference for Project P <br />.-.... �,... (Project # w ) located within the Cityof <br />South Bend, St. Joseph County, Indiana. <br />El Tile location tit"the principal place of business is 644 0 Q 14k, (4) R t) 9,-xml t1C.vo <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 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 ]`or 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, an(] (ii) the total payroll amount paid to employees who are <br />1°esidetlts ol`St. Joseph County and the adjacent county noted above. <br />WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, BIOi1E1t SHALL REDACTALL <br />SOCIAL JFCVR T11't'VUMBE s. <br />t) <br />Dated this day of APAIL 20 f <br />Contractor/Bidder <br />Signature of - .. <br />Cont'actorlBidder or Its Agent <br />Printed Name and Title <br />2 <br />