Att C - Indiana Economic Impact Form.xls
XLS spreadsheet 198 KB Posted
- Attached to
- ISPHN Centralized Billing OfficeBid Documents State and local contract opportunity
- Solicitation number
- RFP 26-86529
- Issued by
- Indiana
About this file
This is an Indiana Economic Impact Form (Attachment C) required by the Indiana Department of Administration for all contractors, vendors, and suppliers conducting business with State of Indiana agencies. The form serves to document economic impact on Indiana and its residents regardless of the contractor's location. Respondents must complete 22 items providing company information including legal name, address, telephone, federal tax identification number, state of incorporation, headquarters location, parent company details if applicable, Department of Workforce Development and Department of Revenue account numbers, Indiana resident employee counts based on IRS Form W-2 distributions, total payroll information for both Indiana residents and all employees, and the total proposal or contract amount. Additionally, contractors must account for full-time equivalent (FTE) employees who are Indiana residents working specifically on the state contract, with detailed breakdowns for both prime contractors and subcontractors.
The form emphasizes accurate FTE calculation methodology, requiring that only Indiana employees dedicating time exclusively or partially to the state contract be counted proportionally. For example, an employee splitting time equally between two projects counts as 0.5 FTE rather than 1.0 FTE. Respondents must populate the FTE Details worksheet with job titles and corresponding FTE contributions, accounting for the number of employees, duration in months, and percentage of time spent on the contract. The initial contract term is 24 months, and the form allows for multiple subcontractor entries. An authorized official must affirm under penalties of perjury that all representations are accurate. This form does not restrict any company from doing business with the state but rather collects data to measure and recognize economic impact on Indiana residents and the state economy.
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Text version
Instructions
| Indiana Economic Impact Form, Attachment C |
| Instructions |
| 1. Complete lines 1 - 15 with the information requested about the company in the Attachment C worksheet. |
All companies desiring to do business with state agencies must complete an “Indiana Economic Impact” form (Attachment C). The collection and recognition of the information collected with the Indiana Economic Impact form places a strong emphasis on the economic impact a project will have on Indiana and its residents regardless of where a business is located. The collection of this information does not restrict any company or firm from doing business with the state.
2. Line 16: Enter total amount of this proposal, bid, or current contract.
This figure is the respondent's total cost proposal to the the state (as sumitted in Attachment D, Cost Proposal Template). Additionally, this total shall be utilized when completing your Attachment A, MWBE Subcontractor Commitment Form.
3. Lines 18 and 21 measure the full-time equivalent (FTE) count of Indiana residents; this number will be auto-populated on Attachment C worksheet. Respondents shall populate the yellow-shaded cells in the FTE Details worksheet.
The state defines FTE as a measurement of an employee's productivity on a specific project or contract. An FTE of 1 would mean that there is one worker fully engaged on a project. If there are two employees each spending 1/2 of their working time on a project that would also equal 1 FTE.
Please populate the yellow-shaded cells in the FTE Details worksheet.
Respondents shall provide a job title for each of the FTE's proposed for The State of Indiana contract as well as the number of FTE that job title contributes to the total.
PROJECT MANAGER - 1 FTE
Please keep in mind that the only FTE's that should be included in this count are Indiana employees working on this contract ONLY. If there are 10 employees working on this contract but they are splitting their time with numerous other contracts as well, then these employees cannot be counted as 1 FTE. Instead, these employees should be counted as a fraction of an FTE. For example: 10 employees working on 4 contracts (1 of them being the State of Indiana contract) - each of the 10 employees would only count as 1/4 of an FTE or .25. Therefore, the total number of FTE's for this scenario would be 2.5.
Attachment C
| 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 | Legal Name of firm: | ||||
| 2 | Address/City/State/Zip Code: | ||||
| 3 | Telephone #/Fax #/Website: | ||||
| 4 | Federal Tax Identification Number: | ||||
| 5 | State/Country of domicile/incorporation: | ||||
| 6 | Location of firm's headquarters or principal place of business: | ||||
| 7 | Name of parent company or holding company (if applicable): | ||||
| 8 | State/Country of domicile/incorporation of company listed in #7: | ||||
| 9 | Address of company listed in #7: | ||||
| 10 | IN Department of Workforce Development (DWD) account number: | ||||
| 11 | IN Department of Revenue (DOR) account number: | ||||
| 12 | Number of Indiana resident employees per most recently completed IRS Form W-2 distribution: | ||||
| 13 | 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: | ||||
| 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: | 0.00 | |||
| 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: | 0.00 | 0.00 | 0.00 | 0.00 |
| 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: |
INDIANA ECONOMIC IMPACT - PROPOSALS AND CONTRACTS
State Form 51778 (R4 / 1-06)
DEPARTMENT OF ADMINISTRATION
Approved by State Board of Accounts, 2006
FTE Details
FTE DETAILS
Job Titles and Contributing FTE
- Populate the yellow-shaded cells; with all applicable job titles and the total FTE count.
- Respondents may insert additional rows to account for all job titles attributing to the total FTE count.
Please keep in mind that the only FTE's that should be included in this count are Indiana employees working on this contract ONLY. If there are 10 employees working on this contract but they are splitting their time with numerous other contracts as well, then these employees cannot be counted as 1 FTE. Instead, these employees should be counted as a fraction of an FTE. For example: The project length of the contract is 24 months. There are 10 employees working on the contract over the 24 month contract period. 5 employees are working solely on the project for 24 months. 3 employees are working equal time on 2 projects for 24 months. 2 employees are working solely on the project for 6 months.
The FTEs would be calculated as follows:
5 employees x 24 months (24 months working solely on this project) x 1 (time spent solely on this project) = 120 months / 24 months (length of contract) = 5 FTEs 3 employees x 24 months x .5 (splitting time equally between 2 projects) = 36 months / 24 months = 1.5 FTEs 2 employees x 6 months (6 months dedicated solely to this project) x 1 (time spent solely on this project) = 12 months / 24 months = .5 FTEs Column Title Definitions:
Number of Employees = Number of employees working on this State contract.
Duration (In Months) = Amount of time that the employee(s) will spend on the State contract.
Time Spent (Percentage) = Percentage of time the employee(s) will be working on the contract.
| Duration of Initial Contract Term (In Months) | 24 | *Number based on initial contract term | ||
| PRIME CONTRACTOR COMPANY | ||||
| EMPLOYEE JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Project Managers | 5 | 24 | 100% | 5.00 |
| Example: Project Coordinators | 3 | 24 | 50% | 1.50 |
| Example: Project Directors | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 |
File details come from the government source that posted it. Updated .