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(To he completed only kip ContractorslBidders claiming to be a "local Indiana business"pursuant to LC 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business " re fiens to an, of lhefiolloii4ng: <br />W A business ii hose principal place ql'biisiness is located in an allected county. <br />(2) A business that pays a inajority qf its pqyroll (in dollar volinne) to residents q 'qfkcted counties. <br />(3) A business .that einplo)?s residents q/'q&cted counties as a majority of enlplqyees, <br />(4) A business that makes significant capital investments in the affected counties as de Jined in rides adopted by the pQlitical <br />sabdivision. <br />(5) A business that has a substantial positive econoinic impact on the aff <br />ected coitnties as tic, fined b,, criteria in rides adygled by <br />the political subdivision. <br />An "affected county" refers to St. Joseph County, Indiana, or thefolloliing co,1111ties located aqiacent to St. Joseph inlY: <br />Elkhart County, Marshall Comity, Starke Comity and LaPorte County <br />There are the.follomingprice preferences fir supplies pia-chased.fivin a local Indiana bitsiness: <br />. 5%fior a purchase expected 4), the purchasing agency to be less than $50, 000 <br />. 3%fir apurchase expected 4y the purchasing ageneY to beat least $50,000 bat less than $100,000. <br />- 1%fora ptirchaseexpected bi, the varchasinzazenci� to be at least $100,000. <br />Date: <br />Pursuant to I.C. 36-1-12-22, <br />preference for Project <br />South Bend, St. Joseph County, Indiana. <br />r-1 The location of the principal place of business <br />(Project ff <br />claiine" a local Indiana business <br />) located within the City of <br />(Address) <br />St. Joseph County, Indiana <br />❑ The following County located adjacent y, Indiana: Coo <br />ty, <br />t. Joseph Cot t <br />❑ The majority of the business's payroll fo,"ihe 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 />r-1 The majority of the bus i ness,"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 deemeddbe 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 SUPIK YING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACT ALL <br />lr SOCIAL SECURITY NUMBERS. <br />Dated this I day of <br />911 <br />Contractor/Bidder (Firm) <br />Signature of Contractor/Bidder or Its Agent <br />Printed Narne and Title <br />