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(To be conipletedonlyby ContractorslBidders clahning to be a "localIndienia business"pursuant to LC 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Ii7diana bushiess " rqfers to any of fhefiolloi�,ing: <br />(1) A bushiess mihose priwipal place qf bush7ess is located iii ail affected collyl�v. <br />(2) A bushiess that pays a incliority qfits pqi,roll (in dollar whiiiie) to residews oj'cff <br />ff�cted coullties. <br />(3) A bushiess that ei;iploys, residews qfq&cted comilies as a iiiajorio, qfits eiiiployees. <br />(4) A hushiess that iiiakes sigii�ficaw capital hwesto?iews ill the affected coiu7ties as dqfined in rules adopled 1)), thepolitical <br />subdivisioii. <br />(5) A bushiess that has a substalaialpositivc ecoi?otitic Mipact oil the affected cowities as dqfh?ed by criteria iir rides adopted by <br />the political mbdi0sion. <br />Ail "af <br />.1kted cowio, " refers to St. Joseph Coraily, hidiaiia, or thefiolloii,big counties located adjacetif to St. Joseph Couno): <br />Elkhart Cowily, Marshall Cowity, Slarke Counb� aoid LaPorte Corinly <br />There are thefbilowhig py-ice preftreiice�sfbr supplies purchased ' fi�oi?i a local lirdiaira business: <br />* 5%.forapurchaseexpec(edh - v the purchashig ageiic ' v to be less thaii $50,000 <br />* 3%fir apurchase expectedki� thepurchasitig agepiQi, to beat least $50,000 but less Mail $100,000. <br />* 1%forapurchaseexpectedby thepurchasingqgeiicy to beat least $100,000. <br />Date: .-A% <br />Pursuant to I.C. 36-1-12-229 claims a local Indiana business <br />preference for Project 9:.� (Project # located within the City of <br />South Bend, St. Joseph County, Indiana. <br />The location of the principal place of business is ... . .......... ..... ...... <br />r-J . (Addres�) <br />St. Joseph County, Indiana <br />The following county located adjacent to St, Joseph County, Indiana: _ <br />Fj 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 />F-1 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 to -%vest, responsible, responsive bidder, then it shall provide <br />supporting documentation for the 12 month period prior to tile 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 PA FROLL RECORDS, BIDDER WALL REDACTALL <br />SOCIAL SECURITY NUMBERS. <br />Dated this 16 day of tkh k 1UR _, 20 1 (; <br />Contractor/Bidder CF4fty&—, <br />Signature of Contractor/Bid�ff,or Its Agent <br />*Aup MIA-0- L- <br />Printed Name and Title <br />8 <br />