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(To be carnpleted only by Contractors/Bidders clahnitng to be a `local Indiana businesss "pursuant to LC 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana bnsincss"r'eJ�rs to arty 41'1he Jolloivirrg. <br />(1) A business whose principal place gf business is located in all affected totally. <br />(2) A business that pays a major'ih' gfits put�roll (ill dollar ethane) to residents of c&cled colonies. <br />(3) A business that employs residents g1'affected cotrrtties as a majority of ifs employees. <br />(4) A business that makes significant capital irt>>cstrrteuts lu the affected counties as dejiued in r nlc.c rrdnprcd its tlrc hnJiticul <br />subdivision. <br />(5) A business that has a strbslattiial positive economic impact on the affected couunties as dc.Jiued hr crilcria ill rates• mdopled by <br />the political subdivision. <br />An "affecledcounty"refers to St, Joseph County, Indiana, or thefollowingcorunties loccrlcclacljac•crrl In St, doseph Count <br />Elkhart County, Marshall Counh� Starke County and Worle County <br />There are the,fnllowvirrg price preJ�r•e aces for supplies purchased front a local Indiana brrsirres•s: <br />• 5%•for a prrrchcrse expected hY the purchasing agency to be less than $50,000 <br />• 3%for a prrrchcrse expected 1w the ptu•chasing agency to beat leers! 950,000 bill less thus 5' l till, 000, <br />• I % for a purchase expected by the: parchasing agency to be at least $100,000. <br />Date: o -3 1 ' I <br />Pursuant to T,C. 36-1-1 -2 fC/.5 �� vwo? claims a local Indiana business <br />preference for Project i' (Project # } located within the City of <br />South Bend, St. Joseph County, Indiana. <br />The location of the principal place of business is --+� <br />NA <br />St, Joseph Cot€nty, 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 elate of'this Bid are residents of <br />St. Joseph County, Indiana, or the adjacent comity 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 laid of lit 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 />WHENSUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACT ALL <br />SOCIAL SECURITYNUiMIBERS. <br />1�1 <br />Dated this day of klpa 20 /.__./V <br />_ <br />.A4 A F. I f r A_. t I. <br />ITer o, it�t` uh6dal' <br />Qi <br />ame and Title <br />