Opening of Bids - Spec K One or More 2018 or Newer Utility Work Machine - Bobcat of Michiana - Bid Security Chk Submitted

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(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 A "local Indiana business" refers to any of thefollowing: (1) A business whose principal place of business is located in an affected county. (2) A business that pays a majority of its payroll (in dollar volume) to residents of affected counties. (3) A business that employs residents of affected counties as a majority of its employees. (4) A business that makes significant capital investments in the affected counties as defined in rules adopted by the political subdivision. (5) A business that has a substantial positive economic impact on the affected counties as defined by criteria in rules adopted by the political subdivision. An "affected county" refers to St. Joseph County, Indiana, or the following counties located adjacent to St. Joseph County: Elkhart County, Marshall County, Starke County and LaPorte County There are the following price preferences for supplies purchased from a local Indiana business: • 5% for a purchase expected by the purchasing agency to be less than $50, 000 • 3% for a purchase expected by the purchasing agency to beat least $50, 000 but less than $100, 000. '...1 "% fora purchase expected the purchasing agency to be at least $100, 000. Date: (q I IR Pursuant to I.C. 5-22-15-20.9, claims a local Indiana business preference for Project mmmmm ._._..._._._�. ................. (Project # ) located within the City of South Bend, St. Joseph County, Indiana. The location of the principal place of business is a..y 7 Old Q s 3 3 ............______ 1 K hex rt _ �______ , (Ar dry ss) (o ❑ St. Joseph County, Indiana The following county located adjacent to St. Joseph County, Indiana: ❑ The majority of the business's payroll for the 12 months prior to the date of this Bid is to residents of St. Joseph County, Indiana or the adjacent county noted above. ❑ The majority of the business's employees for the 12 months prior to the date of this Bid are residents of St. Joseph County, Indiana, or the adjacent county noted above. If the business is deemed to be the apparent lowest, responsible, responsive bidder, then it shall provide supporting documentation for the 12 month period prior to the date of the Bid of (i) the total payroll amount paid to all employees of the business, and (ii) the total payroll amount paid to employees who are residents of St. Joseph County and the adjacent county noted above. WHEN SUPPLYING SUPPORTING PAYROLL RECORDS, BIDDER SHALL REDACTALL SOCIAL SECURITYNUMBERS. Dated thisday of ...................... ................20 m....__._.......................................... I . Contiaclo° :aid (F' ) Signature of Contractor/Bidder or Its Agent C � Name and. �.. � ....... �� C t Printed c _ Tit e....... ............................... IN