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(To be completed only by Contractors/Bidders claiming to be a "local Indiana business" pursuant to I.C. <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 de fined in rutp adopted by the political <br />subdivision. 1 <br />(5) A business that has a substantial positive economic impact on the affected counties as die fi"rred by criteria in rules adopted by <br />the political subdivision. /, <br />An "affected county" refers to St. Joseph County, Indiana, or the following counties lilted 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 Ip iana business: <br />• 5% for a purchase expected by the purchasing agency to be less di,ati0,000 <br />• 3% for a purchase expected by the purchasing agency to beat leas 50,000' but less than $100,000. <br />• 1%;fbr a purchose expected by the purchasing agency to be at le(td"to$100,000, <br />Date: <br />Pursuant to I.C. 5-22-15-20.9, <br />preference for Project <br />South Bend, St. Joseph County, Indiana. <br />claims a local Indiana business <br />(Project # --------- J located within the City of <br />I� . The location of the principal pla of business is <br />(Address) <br />St. Joseph County, tdiana <br />f The following unty located adjacent to St. Joseph County, Indiana: <br />The m/ofusiness's payroll for the 12 months prior to the date of this Bid is to residents of St. <br />Josepha or the adjacent county noted above. <br />The mausiness's employees for the 12 months prior to the date of this Bid are residents of <br />St. Josediana, or the adjacent county noted above. <br />If the busi 'ss is deemed to be the apparent lowest, responsible, responsive bidder, then it shall provide <br />snpporti documentation for the 12 month period prior to the date of the Bid of (i) the total payroll <br />a ou„ paid to all employees of the business, and (ii) the total payroll amount paid to employees who are <br />res' tints of St. Joseph County and the adjacent county noted above. <br />WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, )UPPER SHALLMDACIALL <br />SOCIAL ITY'NLL <br />Dated this day of(V� (,- %A� 20L Ck <br />cTAV E M 4r� T,.^C <br />Contractor/Bidder r l <br />Signature of Conlrdoor idder or I Agent <br />V G k` 5 I Og g <br />Printed Name and Title <br />Nov <br />