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(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 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'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 "aff"ected 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 log 'I&'i' a $50, 000 <br />• 3% far a purchase expected by the purchasing agency to beat least $50, 000 but less than $100, 000. <br />• 1 % for a purchase _expected by the purchasing agency to -be at least $100, 000. <br />Date: llhy J 3 o l9 <br />G claims a local Indiana business <br />Pursuant to I.C. 5-22-15-20.9,..�.� ...-.i..'!` k . ..!c �C n.... .......... <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 �0L i�,h U103-, <br />W 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 SIMLL, REI)A.CT,ALI., <br />SOCIAL SECURITYNUMBERS. <br />... <br />Dated this _ ck_3__Zj4, day of ���...........e..m.........., 20 <br />Ali L _ ( 1�LAC, .: ..AQ <br />Coretoi-/Bidder 4 <br />Sggnatum of Contractor/Bidder or Its Agent <br />Pi-inted'Name aiad "1 itic <br />G <br />