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Not Applicable <br />(To be completed only by Contractors/Bidders 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 lhefiolloiving: <br />(1) A business iMose 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 lMed 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 aff <br />ected counties as defined by criteria in rules adopted by <br />the political subdivision. <br />An "eff <br />ected refers to St. Joseph County, Indiana, or the JbIloiving counties located adjacent to St. Joseph County <br />Elkhart County, iWarshall County, Starke County and LaPorte County <br />There are thefiolloiOng price prq/crences.for supplies purchased from a local Indiana business- <br />* 5%for apurchuse 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 $/00,000, <br />least $100,000, <br />Date: <br />Pursuant to I.C. 5-22-15-20,9, _ITmmmmclaims a local Indiana business <br />preference for Project . . ... . ............ .......................................... — (Project # located within the City of <br />South Bend, St. Joseph County, Indiana. <br />❑ The location of the principal place of business is ­­­­­ . .......... <br />(Addre <br />F-1 St, Joseph County, Indiana <br />❑ The following county located adjacent to St. Joseph County, Indiana:— <br />F-1 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 />WHENSUPPL YING SUPPORTING PA YROLL RECORDS, BIDDER SHALL REDACTALL <br />SOCIAL SECURITYNUMBERS. <br />Dated this ____ _ day of 20 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />