Free 51778.xls - Indiana

INDIANA ECONOMIC IMPACT - PROPOSALS AND CONTRACTS
State Form 51778 (R5 / 3-06)

DEPARTMENT OF ADMINISTRATION Approved by State Board of Accounts, 2006

This information is required by the Indiana Department of Administration for all contractors, vendors/suppliers to the State of Indiana (complete all 22 items). 1 2 3 4 5 6 Legal Name of firm: Address/City/State/Zip Code: Telephone #/Fax #/Website: Federal Tax Identification Number: State/Country of domicile/incorporation: Location of firm's headquarters or principal place of business: Name of parent company or holding company (if applicable): State/Country of domicile/incorporation of company listed in #7: Address of company listed in #7: IN Department of Workforce Development (DWD) account number: IN Department of Revenue (DOR) account number: Number of Indiana resident employees per most recently completed IRS Form W-2 distribution: Total number of employees per most recently completed IRS Form W-2 distribution: 14 Total amount of payroll paid to Indiana resident employees per most recently completed IRS Form W-2 distribution: 15 Total amount of payroll paid to all employees per the most recently completed IRS Form W-2 distribution: 16 Total amount of this proposal, bid, or current contract:

7

8

9 10

11 12

13

1

ACCOUNTING OF INDIANA RESIDENT EMPLOYEES 17 Prime Contractor Company Name: 18 Number of Full Time Equivalent (FTE) employees that are Indiana residents specifically for this proposal or contract: 19 Subcontractor Company Name: 20 Address/Contact Person/Telephone Number/Tax ID Number: 21 Number of Full Time Equivalent (FTE) employees that are Indiana residents specifically for this proposal or contract: 22 Affirmation by authorized official: I affirm under penalties of perjury that the foregoing representations are true to be the best of my knowledge and belief: Signature: Name of auththorized official: Title: Date:

2