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RLYZICURNOMMI" MI
<br />(To be completed only by Conlractour slBdders claiming to be a "local IpOana busfnass" plursuant to 1� C 36- 1 - 12-22)
<br />A "local Indiana business " refers to any of the f6ficiwing:
<br />(1) A businesswhose principal pface ol"husiness is )dcated In an affactedcounty.
<br />business, that pays a mainfity ofils payrafl (in dollar volurne) to residents of affktad counfies'.
<br />(3), A business that employs rest rout of Offeclad counlies as a majprify of ils efROOYee's,'
<br />(4), A business that makes significant capital investments In, the affected coundes as, defhled in rules adopted by the,
<br />polifical subdivisl6n.
<br />(5), A hosiness that has a substantial positive aconomk impact on the affected counties, as deffnedtry offteda in rules
<br />adopted by the pohlical subdivision.
<br />1* a 47 110, 1 .0 i WT"f I , R
<br />CoPorte Counly
<br />rhen are the foll6wing price, prefere,�ncos for supplies purchased from a local Indiana buslness:
<br />* 5% for a purchase, expected by the, purchasing agency to, be &j5j-LIvn $50,000
<br />* 3% for a purchase expe�cted by the, purchasing agenoy to, be at least $50,000 but lass than $100,000.
<br />* 1 % kr a pqThq atected b , the q.a',,,least $100,000,
<br />........ . . . ...... . ..........
<br />Pursuant to, LC �, 36-1 Al 22 claims, a local Indjana busInjess
<br />prefere=,e for Project 1 11 —.- . ........... . ....... (Project # —,,_) located within the City of
<br />South Rend, St Joseph County, Indiana
<br />0 The location of the principal, place of'busibess is — . . . ............ ..
<br />fAd[*@9S)
<br />St, J'cvs,eph County, Indiana
<br />0 The fb[lowing county losaph County, lndlana�
<br />U the majoirity ofthe 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'r
<br />ID The maj,041ty of the bu al ness's employes for the 112 months, prior to the dale of this Bid are residents of St,
<br />Joseph, County,, I rj(djana, or the adjacent counly noted above..
<br />If the bualness is deerned to be the apparent lowest, responsible. responsi've bidder, then fit sheik provicle
<br />supporting diocumentation for the 12 month perlod, prior to the date of the Bid opt' (1), the: total payroll amount
<br />paid to all employees of the Ibusines,5, and (11) the total payroll airviouinit paid, to employees who are residents
<br />of S,L Joseph County and the adjacent county noted above.
<br />MIEN SUPPLYING SUPPORTMG PAYROLL RECORDS,
<br />Dated this, day of , 20�--
<br />ContractOTIBiddoer (Firm
<br />-do-n- -t-ra. 6 t o.—H El Id de rj a r I ts Age nt
<br />Printed Name and Title
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