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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 BUSINESS PREFERENCE CLAIM <br />_.................. ..... <br />A "local Indiana business " refers to any of the fallowing: <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'aff"ected 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 "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 preferencesfor supplies purchased from a local Indiana business: <br />• 5% for a purchase expected by the purchasing agency to be levy i'hy(l $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 beat least $100, 000. <br />Date: 11 '/ " <br />Pursuant to I.C. 5-22-15-20.9, .............. ...................................u...r.....1-�....... ...nC,.................................. <br />claims 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 f t"S„ tJ <br />St. Joseph County, Indiana <br />❑ The following county located adjacent to St. Joseph County, Indiana: <br />F 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 />WHEN SUPPL YING SUPPORTING PAYROLL RECORDS, BID . ER SHALL REDACTALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this.- ....3.... ..... day of . i)AcL ......... A.........� 20� <br />(Fmn) <br />Si,;Z'I LAi of ContractorB <br />g idder or Its Its Agent <br />�►Iler <br />Printed Name andTi `i Ile <br />rol <br />