Att C - Indiana Economic Impact Form.xls
XLS spreadsheet 196 KB Posted
- Attached to
- DDB Speech and Language ConsultationBid Documents State and local contract opportunity
- Solicitation number
- RFP 26-87266
- Issued by
- Marion County, Indiana
About this file
This is an Indiana Economic Impact Form (State Form 51778) required by the Indiana Department of Administration for all contractors, vendors, and suppliers seeking to do business with state agencies. The form emphasizes the economic impact a proposed project will have on Indiana and its residents, regardless of the contractor's location. All companies must complete the form, which consists of 22 line items requesting company information including legal name, address, federal tax identification number, state of domicile, headquarters location, parent company details if applicable, and Indiana Department of Workforce Development and Department of Revenue account numbers.
The form requires respondents to report Indiana resident employee data from the most recently completed IRS Form W-2 distribution, including the number of Indiana resident employees, total employees, and payroll amounts for both Indiana residents and all employees. Respondents must also account for full-time equivalent (FTE) employees that are Indiana residents working specifically on the proposed contract or project. An FTE is calculated by multiplying the number of employees by contract duration in months, by the percentage of time spent on the contract, then dividing by the total contract term length. The form includes detailed worksheets for documenting job titles, number of employees, duration of work, and time allocation percentages for both prime contractors and subcontractors, with an initial contract term of 24 months used as the calculation baseline. An authorized official must sign an affirmation under penalties of perjury certifying the accuracy of all representations provided.
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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).
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 .