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(To be completed only by Contrao <br />INDIANA <br />A "local Indiana business" refers to any <br />(1) A business whose principal place of i <br />(2) A business that pays a majority of its <br />(3) A business that employs residents of <br />(4) A business that makes significant cal <br />subdivision. <br />(5) A business that has a substantial pos <br />the political subdivision. <br />An "affected county" refers to St. Joseph <br />Elkhart County, Marshall County, Starke <br />There are the following price preferences <br />• 5% for a purchase expected by the <br />• 3 % for a purchase expected by the <br />• 1 % for a purchase expected by the, <br />Date: <br />Pursuant to I.C. 5-22-15-20.9, <br />preference for Project <br />South Bend, St. Joseph County, ] <br />the <br />claiming to be a "locallndiana business" pursuant to I.C. 36-1-12-22) <br />BUSINESS PREFERENCE CLAIM <br />is located in an affected county. <br />(in dollar volume) to residents of affected counties. <br />counties as a majority of its employees. <br />,stments in the affected counties as defined in rules adopted by the political <br />impact on the affected counties as defined by criteria in rules adopted by <br />Indiana, or the following counties located adjacent to St. Joseph County: <br />and LaPorte County <br />purchased from a local Indiana business: <br />agency to be less than $50, 000 <br />agency to be at least $50, 000 but less than $100, 000. <br />wencv to be at least $100, 000. <br />claims a local Indiana business <br />(Project # ) located within the City of <br />❑ The location of the principal p ace of business is <br />(Address) <br />❑ St. Joseph County, Im iana <br />❑ The following cc unty located adjacent to St. Joseph County, Indiana: <br />❑ The majority of the busi ess' payroll for the 12 months prior to the date of this Bid is to residents of St. <br />Joseph County, Indiana r the djacent county noted above. <br />❑ The majority of the busi es-' employees for the 12 months prior to the date of this Bid are residents of <br />St. Joseph County, Indi a, or the adjacent county noted above. <br />If the business is deemed to be e a arent lowest, responsible, responsive bidder, then it shall provide <br />supporting documentation for 12 month period prior to the date of the Bid of (i) the total payroll <br />amount paid to all employees of he b siness, and (ii) the total payroll amount paid to employees who are <br />residents of St. Joseph County an I the adjacent county noted above. <br />WHEN SUPPL YING SUPPIDRT�NG PAYROLL RECORDS, BIDDER SHALL REDACT ALL <br />Dated this day of 1 1 , 20 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />