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(To be completed only by Contractors/Bidders claiming to be a "locallndiana business"pursuant to LC. 36-142-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business" refers to any of dre,folloxiing: <br />(1) A business whose principal place of business is located in an affected couno) . <br />(2) A business that pays a najority of its payroll (in dollar vohnne) 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 rides adopted by the political <br />subdivision. <br />(S) 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 ac jacent to St. Joseph Counh�• <br />Elkhart County, Marshall County, Starke County and LaPorte County <br />There are the. following price preferences,for supplies pun•chased from a local Indiana business: <br />S%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, <br />business preference for Project <br />within the City of South Bend, St. Joseph County, Indiana, <br />The location of the principal place of business is <br />claims a local Indiana <br />(Project # )located <br />(.9ddress) <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 <br />residents of St. 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 <br />residents of 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 <br />provide supporting documentation for the 12 month period prior to the date of the Bid of (i) the <br />total payroll amount paid to all employees of the business, and (ii) the total payroll amount paid <br />to employees who are residents of St. Joseph County and the adjacent county noted above. <br />WHEN S UPPL YING S UPPOR TING PAYROLL RECORDS, BIDDER SHALL REDACT <br />ALL SOCIAL SECURITY NUMBERS. <br />Dated this <br />day of <br />20 <br />ContractorBidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Name and Title <br />