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(To be completed only by Corttractor.VBidd ers claiming to be a "local Indiana business" pursuant to I. C. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business" refers to any of the following: <br />(1) A business whose principal place of business is located in an affected county. <br />(2) A business that pays a inajority of its payroll (in dollar volume) 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 sign cant capital Investments in the affected counties as defined to rules adopted by the political <br />subdivision. <br />(5) A business that has a substantial positive economic impact on the affected counties as damned 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 adjacent to St. Joseph County: <br />Elkhart County, Marshall County, Starke County and LaPorte County <br />There are the following price preferences for supplies purchased from a local Indiana business, <br />• 5% 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 purchastMgg .2 to be at least $100.000. <br />Date: <br />Pursuant to I.C. 5-22-15-20.9, r 2i ("Laz", i �.�q .m ��'„ claims a local Indiana business <br />preference for Project lc. i1 ) ,� xp: b " I � '... ...� (Project # ,.ter : VV '1 located within the City of <br />South Bend, St. Joseph County, Indiana. <br />The location of the principal place of business is 14 4„ 1.. ,t l <br />M.. t,�drtr�rl <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 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 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 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 SUPPLYING SUPPOR TING PA YROLL RECORDS, WIDDER 19 Ll IiA+ "TAL <br />SOCUL SECURITY NUMBERS. <br />Dated this /, day of tl , 201 " <br />Contractor/Bidder or Its Agent <br />Printed Name and Title <br />6 <br />