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(To be completed only ky ContractorslBidders claiming to be a "local Indiana business"pursuant to L C. 36-1-12-22) <br />INDIANA LOCAL BUSINESS PREFERENCE CLAIM <br />A "local Indiana business'" re P,rs to any y cif <br />thefinflowing, - <br />(1) A business whose princip al place qfbusiness is located in an q1tected county. <br />(2) A business thatpqys a majority ql'its payroll (in dollar volume) to residenty qfql) I ey ,fee ed co unt i <br />(3).A busdness, that enipkys residents q1'af ,jected counties as a majoritv qf its employees. <br />(4) A business that inakes sign4icant capital investments in the aj te ,fec d countie.s as dolned in riikw adopted bY the political <br />subdivision. <br />(5) A business that has a substantial positive economic impact on the affected counties as de Y <br />fined b criteria in rules adopted 1ly <br />the polifical subdivision. <br />An ""aft cted county " reters to St. Joseph County, Indiana, at- the.1611mving counties located adjacent to St. Joseph County. - <br />Elkhart Couqy, Marshall County, Starke and LaPorte Count y <br />There are the or -,vi <br />* 5% followi),igpi-iceprd,�-r•t?nee�vf ippli,evput-(.,hciseel,fi-()m(tlocallnditinabusitte,.VV: <br />,for a purchase erpected ky the purchasing al,,ency to be less than 50,000 <br />* 3%,lbr apurchase expected by thepurchasing agency to beat least $50,000 but less than $100,000. <br />_p*.ase e. ected.AyllzepLLa!ing q&qy o he qt least $ 00 000, <br />Date: q — g — 10 "L 0 <br />Pursuant to I.C. 5-22-15-20.9, <br />preference for Project <br />South Bend, St, Joseph County, Indiana. <br />Tvt 6- claims a local Indiana business <br />(Project located within the City of <br />The location of the principal place of business is <br />V, <br />El St. Joseph County, Indiana (Addrews) <br />The following county located adjacent to St. Joseph County, Indiana:._L <br />E] 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 />arnount 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 YROLL RECORDS, BIDDER SHALL REDA CTALL <br />SOLIAL SECURITYNUMBERS, <br />Dated this w.day of )-G/ 2o 2.0 <br />6 <br />Con actor/Bidder nfa,�— <br />Signatu of ontractor/Bidder car its Agent <br />---- I) V1k. , k 0 A16% <br />" a�4s� <br />Printed Na and Title <br />z <br />