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County Form 4 - AFFIDAVIT OF PRICE PREFERENCES
I. SECTION ONE: LIMITATIONS
A. A VENDOR WHO CLAIMS THE LOCAL BUSINESS PREFERENCE IN SECTION TWO IS LIMITED TO ONLY ONE MORE SELECTION FROM EITHER SECTION THREE, SECTION FOUR, OR SECTION FIVE. A VENDOR WHO CLAIMS A LOCAL BUSINESS PREFERENCE IN SECTION TWO BUT CLAIMS TWO OR MORE PREFERENCES IN SECTIONS THREE, FOUR AND FIVE WILL SIMPLY LOSE THE ADDITIONAL CLAIMED PREFERENCES.
B. A VENDOR WHO IS NOT A LOCAL BUSINESS OR A VENDOR WHO IS A LOCAL BUSINESS BUT DOES NOT CLAIM THE PREFERENCE CAN CLAIM ONLY ONE PREFERENCE FROM EITHER SECTION THREE, SECTION FOUR, OR SECTION FIVE.
II. SECTION TWO: LOCAL BUSINESS PRICE PREFERENCE
A. This vendor qualifies for the local business preference under IC 5-22-15-20.9 because (please indicate with an X).
______ The principle place of business is in Lake, Porter, Newton, or Jasper County.
______ The majority of the businesses payroll is paid to residents of Lake, Porter, Newton, or Jasper County.
______ The majority of the businesses employees reside in Lake, Porter, Newton, or Jasper County.
B. The Vendor claims the following local business price preference based on the vendor's total offer (please indicate with an X).
______ Five 5% percent on the total offer with is less than $50,000.00.
______ Three 3% percent on the total offer which between $50,000 but less than $100,000.
______ One 1% percent on the offer which is $100,000 or more.
III. SECTION THREE: PREFERENCE FOR AN INDIANA SMALL BUSINESS
A. This vendor is an Indiana small business as defined in IC 5-22-14-1 because the vendor (please indicate with an X).
______ Is independently owned and operated, and
______ Is not dominant in its field of operation.
B. This vendor meets both of the criteria in III. A. above and also meets the following criteria (vendor may select only one of the following by placing an X).
______ Is a wholesale business with annual sales in the most recent fiscal year less than $4,000,000.
______ Is a construction business with average annual receipts for the preceding three fiscal years less than $4,000,000.
______ Is a retail business or a business selling services with annual sales and receipts less than $500,000.
______ Is a manufacturing business with less than 100 employees.
C. This vendor claims the 15.0% small business preference
IV. SECTION FOUR: PRODUCT COMPOSITION PRICE PREFERENCES
A. Product composition price preference (vendor may select only one of the following by placing an X).
______ Ten 10% percent under IC 5-22-15-16 for recycled materials.
______ Ten 10% percent under IC 5-22-15-18 for soybean oil based ink.
______ Twenty 20% percent under IC 5-22-15-19 for soy fuel.
______ Ten 10% percent under IC 5-22-15-23.5 for Indiana farm produce.
______ Ten 10% percent under IC 5-22-15-20.7 for indoor air quality inspections and evaluations.
V. SECTION FIVE: MINORITY BUSINESS ENTERPRISE (MBE) or WOMEN’S BUSINESS ENTERPRISE (WBE)
A. The vendor meets the criteria for an MBE OR WBE - See below.
B. There are price preferences in accordance with Lake County Council Ordinance 1405E-1 as follows:
1. A five (5) % price preference for any proposal; or offer less than one hundred thousand dollars ($100,000.00).
2. A three (3) % price preference for any proposal; or offer one hundred thousand dollars ($100,000.00) and over.
3. A company that is both an MBE and WBE qualifies for both preferences.
C. ______________ Claims an MBE preference
D. ______________ Claims a WBE preference
COMPANY REPRESENTATIVE SIGNATURE
SUBSCRIBED AND SWORN to before me, a Notary Public in and for said County and
State, this _____ day of __________________, 20___.
RESIDENT OF ____________ COUNTY