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4 <br />(To be completed only by Contractors/Bidders claiming to be a “local Indiana business” pursuant to I.C. 36-1-12-22) 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 “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 preferences for supplies purchased from a local Indiana business: <br />•5% for a purchase expected by the purchasing agency to be less than $50,000 <br />•3% for a purchase expected by the purchasing agency to be at 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: ________________________ <br />Pursuant to I.C. 5-22-15-20.9, ________________________________________ 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 _________________________________________: <br />(Address) <br />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 />WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACT ALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this __________ day of ______________, 20_____ <br />____________________________________ <br />Contractor/Bidder (Firm) <br />____________________________________ <br />Signature of Contractor/Bidder or Its Agent <br />____________________________________ <br />Printed Name and Title <br />01/10/2023 <br />NA <br />x Arkansas <br />10 Jan 23 <br />Green Dream International LLC <br />Varand Vartanian, President