ORDINANCE
££ /r ORDAINED B Y THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. Title 17, of the Municipal Code of Chicago, the Chicago Zoning Ordinance be amended by changing all the B3-2 Community Shopping District symbols and indications as shown on Map No. 1 1-H in the area bounded by
A line 199.03 feet south of and parallel to West Berteau Avenue: the alley east of and parallel to North Western Avenue: a line 249.03 feet south of and parallel to West Berteau Avenue: and North Western Avenue
to those of a B2-3 Neighborhood Mixed-Use District.
SECTION2. This ordinance shall be in force and effect from and after its passage and due publication.
4137-4139 North Western Avenue
'A.DGS °
CITY OF CHICAGO
APPLICATION FOR AN AMENDMENT TO U a<)C\i n-z ,7 ,-.o THE Ci. 1'ICAGO ZONING ORDINANCE ' ^-^^
ADDRESS of ihe properly Applicant is seeking lo rezone: 4137-4139 North Western Avenue. Chicago. Illinois
2. Ward Number that properly is located: 47_
APPLICANTS: 4137 Western LLC md 4139 Western LLC
ADDRESS: 4137 North Western Avenue CITY: Chicaco
STATE: Illinois ZIP CODE: 60618 PHONE: 312-782-1983
EMAIL: s?.ra,;;,s«'uii:;a;:i^;.i\v.con;. CONTACT PERSON: Sara Barnes - Attorney for Applicant
Is the Applicant the owner ofthe property? YES X NO .
If the Applicant is not the owner ofthe property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed.
OWNER: Same as Above
ADDRESS: CITY:
STATE: ZIP CODE: PHONE:
EMAIL: CONTACT PERSON:
5. Ifthe Applicant/Owner ofthe property lias obtained a lawyer as their representative for the rezoning. please provide the following information:
ATTORNEY: Sara K. Barnes - Law Offices of Samuel V.P. Banks
ADDRESS: 221 North LaSalle Street. 38th Floor
CITY: Chicago STATE: Illinois ZIP CODE: 60601
PHONE: (3121 782-1983 FAX: 312-782-2433 EMAIL: sara^sambanksiaw.c-
Ifthe applicant is a legal entity (Corporation, LLC, Partnership, etc.), please provide the names of all owners as disclosed on the Economic Disclosure Statements.
Azcem Khan - Managing Member (4137 Western LLC and 4139 Western LLC)
On what date did the owner acquire legal title to the subject property?
January 2013 (4139 North Western Avenue); June 2017 (4137 North Western Avenue)
Has the present owner previously rezoned this property? If Yes, when? No
Present Zoning District: B3-2 Proposed Zoning District: B2-3
Lot size in square feet (or dimensions): 50 feet x 107.13 feet; 5,356.5 square feet (recorded)
Current Use of the Property: The subject property consists of two contiguous lots of record. Each
parcel (Lot 513 and Lot 514) is presently improved with a three-story mixed-use building and a
detached garage. *[777g Applicants presently operate their offices within the ground floor ofthe
4137 building.}
Reason for rezoning the property: The Applicants are seeking a Zoning Map Amendment in order
to raze the existing structures and to redevelop the site, in its entirety, with a new four-story eight-
unit residential building, with off-street parking for eight vehicles.
Describe the proposed use of the property after the rezoning. Indicate the number of dwelling unit number of parking spaces; approximate square footage ofany commercial space; and height of the proposed building. (BE SPECIFIC) The subject property consists of two contiguous lots of record. Each parcel (Lot 513 and Lot 514) is presently improved with a three-story mixed-use building and a detached garage. *\The Applicants presently operate their offices within the ground floor ofthe 4137 building.] The Applicants are seeking a Zoning Map Amendment in order to raze the existing structures and to redevelop the site, in its entirety, with a new four-story (with basement) multi-unit residential building, with off-street vehicular parking for each unit. The new proposed building will feature a total of eight (8) dwelling units, located on and between the Basement thru 4th Floors. The programming for the new proposed development calls for the provision of parking for four (4) vehicles within the interior of the building (Basement), as well as surface parking for four (4) additional vehicles, at the rear of the site. So that the new proposed development will provide onsite parking for a total of eight (8) vehicles. The design for the new
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stair enclosures and a single elevator enclosure. The new proposed building will measure 46-feet
in height (to the underside of the roof structure) and will be masonry in construction.
The Affordable Requirements Ordinance (ARO) requires on-site affordable housing units and/or a financial contribution for residential housing projects with ten or more units that receive a zoning change which, among other triggers, increases the allowable floor area, or, for existing Planned Developments, increases the number of units (see attached fact sheet or visit www.cityofchicago.org/ARO for more information). Is this project subject to the ARO?
NO X
COUNTY OF COOK STATE OF ILLINOIS
I, AZEEM KHAN, being first duly sworn on oath, state that all of the above statements and the statements contained in the documents submitted herewith are true and correct.
Signature of Applicant
Subscribed and swom to before me this
1th day jof rfofrCii
Notary Pujzrlk
OFFICIAL SEAL SARA K BARNES
NOTARY PUBLIC, STATE OF ILLINOIS My Commission Expires 11/15/2024
Date of Introduction:
File Number:
Ward:
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Written Notice, Form of Affidavit: Section 17-13-0.107
March 23, 2022
Honorable 'Thomas Tunney Chairman, Committee on Zoning -121 North LaSalle Street Room 304 - City Hall Chicago, Illinois 60602
To Whom It May Concern:
The undersigned. Sara Barnes, being first duly sworn on oath, deposes and says the following:
That the undersigned certifies that she has complied with the requirements of Section 17-13-0107 ofthe Zoning Code ofthe City of Chicago, by sending written notice to such property owners who appear to be the owners ofthe property within thc subject area not solely owned by the Applicant, and on the owners of all property within 250 feet in each direction ofthe lot line ofthe subject properly, exclusive ofthe public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. That said written notice was sent by USPS First Class Mail no more than 30 days before filing the application.
That the undersigned certifies that the notice contained the address of the property sought to be rezoned as 4137-4139 North Western Avenue, Chicago, Illinois; a statement of intended use of said property; the names and address ofthe Applicants-Property Owners; and a statement that the Applicant intends to file an application for a change in zoning on approximately March 23, 2022.
That the Applicant has made a bonafidc effort to determine the addresses ofthe parties to be notified under Section 17-13-0107 of the Zoning Code of the City of Chicago and that the Applicant certifies that the accompanying list of names and addresses of surrounding property owners within 250 feet is a complete list containing the names and last known addresses of the owners ofthe property required to be served.
Law Offices of Samuel V.P. Banks
Sara K. Barnes Attorney for Applicants
, OFFICIAL SEAL ,
VINCENZO SERGIO •
« NOTARY PUBLIC, STATE OF ILLINOIS >
< My Commission Expires JANUARY 5. 2024 >
PUBLIC NOTICE
Via USPS Fust Class Mail March 23. 2022 Dear Sir or Madam:
In accordance with Amendment to the Zoning Code enacted by the City Council. Section 17-13-0107-A. please be informed that on or about March 23, 2022. I. the undersigned, intend to file an application for a change in zoning from a 83-2 Community Shopping District to an B2-3 Neighborhood Mixed-Use District, on behalf of the Applicants-Property Owners - 4137 Western LLC and 4139 Western LLC. for the property generally located at 4137-4139 North Western Avenue, Chicago, Illinois.
The subject property consists of two contiguous lots of record. Each parcel (Lot 513 and Lot 514) is presently improved with a three-story mixed-use building and a detached garage. *[The Applicants present/)' operate their offices within the ground floor of the 4137 building.] The Applicants are seeking a Zoning Map Amendment in order to raze the existing structures and to redevelop thc site, in its entirety, with a new four-story (with basement) multi-unit residential building, with off-street vehicular parking for each unit. The new proposed building will feature a total of eight (S) dwelling units, located on and between the Basement thru 4lh floors. The programming for the new proposed- development calls for the provision of parking for four (4) vehicles within the interior ofthe building (Basement), as well as surface parking for four (4) additional vehicles, at the rear of the site. So that the new proposed development will provide onsite parking for a total of eight (8) vehicles. T he design for the new development also includes a rooftop deck above thc 4"1 Floor, which will be accessed via two small stair enclosures and a single elevator enclosure. The new proposed building will measure 46-feet in height (to the underside of the roof structure) and will be masonry in construction.
The Applicants and Properly Owners - 4137 Western LLC and 4139 Western LLC are located at 4137 North Western Avenue, Chicago. Illinois.
The contact person for this applicalion is Sara K. Barnes (Attorney for Applicants). My address is 221 North LaSalle Street, 38th Floor. Chicago, Illinois. My telephone number is 312-782-1983.
Very truly yours,
LAW OFFICES OF SAMUEL V.P. BANKS
Se-re^ K. hwtiefr.
Sara K. Barnes Attorney for Applicants
"--Please note that the Applicant is NOT seeking to purchase or rezone your property. "--The Applicant is required by law to send this notice because you own property located within 250 feet ofthe property subject to the proposed Zoning Amendment.
To whom it may concern:
I, AZEEM KHAN, on behalf of 4137 Western LLC and 4139 Western LLC - the Applicants and Owners, with regard to the properties generally located at and comprising 4137-4139 North Western Avenue, Chicago, Illinois, authorize the Law Offices of Samuel V.P. Banks, to file an application for a Zoning Map Amendment, with and before the City of Chicago, for and affecting such properties.
Azeem Khan 4137 Western LLC 4139 Western LLC
-FORM OF AFFIDAVTT-
Chairman Thomas Tunney
Committee on Zoning
City of Chicago - City Hall
121 North LaSalle Street - Room 304
Chicago, Illinois 60602
RE: 4137-4139 North Western Avenue, Chicago, Illinois Application for Zoning Map Amendment
Dear Chairman Tunney:
L AZEEM KHAN, on behalf of 4137 Western LLC and 4139 Western LLC, understand
that the Law Offices of Samuel V.P. Banks has filed a sworn affidavit identifying 4137 Western
LLC and 4139 Western LLC as holding interest in certain land subject to the proposed Zoning
Map Amendment - for the properties commonly identified as 4137-4139 North Western Avenue,
Chicago, Illinois.
L AZEEM KHAN, being first duly sworn under oath, depose and say that 4137 Western LLC and 4139 Western LLC hold those interests for themselves and for no other person, association, or shareholder.
3/1 / ^
Azeem Khan Date
Subs this
bed and sworn to beforj?me day of Mmich
~~~r\ «n (q *n. <^ *rr*m
OFFiCPrtrSEAL SARA K BARNES
NOTARY PUBLIC, STATE OF ILLINOIS My Commission Expires 11/15/2024
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 4137 Western LLC
Cheek ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
_/J the Property Owner and Applicant
OR
Q a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred lo below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR.
[]] a legal entity with a direct or indirect right of control ofthe Applicant (see Section 11(B)(1)) State the legal name ofthe entity in which the Disclosing Party holds a right of control:
B. Business address ofthe Disclosing Party: 4137 North Western Avenue
Chicago, Illinois 60618
C Telephone- 312-782-1983 pax: N/A Email: sara@sambankslaw.com
Name of contact person: Sara Barnes - Attorney for Applicants
Federal Employer Identification No. (if you have one):
Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if applicable):
The Applicant is seeking a Zoning Map Amendment for and affecting 4137-4139 North Western Avenue.
Which City agency or department is requesting this EDS? DPD
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification. # and Contract #
Ver.2018-1 Page 1 of 15
I
SECTION ll - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature ofthe Disclosing Party:
Person \/\ Limited liability company
Publicly registered business coiporation [~J Limited liability partnership
Privately held business corporation f~J Joint venture
Sole proprietorship [~J Not-for-profit corporation
General partnership (Is the not-for-profit corporation also a 501 (c)(3))?
Limited partnership Yes [ \ No
Trust Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
linois
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
| [ Yes [~J No [/] Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, ifany, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party: (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general, partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Azeem Khan Managing Member
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legai entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Azeem Khan 4137 North Western Avenue, Chicago, Illinois 60618 50%
Raheem Khan 4137 North Western Avenue, Chicago, Illinois 60618 50%
SECTION Hi - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? r-J Yes / No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? r-J Yes [/J No
If "yes" to either of the above, please identify below the name(s) of such City elected ofncial(s) and describe such income or compensation:
Does any City elected official or, to the best ofthe Disclosing Party's knowledge after reasonable
inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in
Chapter 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosing Party?
[] Yes [7] No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor; attorney. paid or estimated.) NOTE:
to be retained) lobbyist, etc.) ''hourly rate" or "t.b.d." is
not an acceptable response,
Sara Barnes - Law Offices of Samuol VP Banks Attorneys (Retained) S12.500 (est )/S6,500 (paid)
221 North LaSalie Street, 38th Floor, Chicago, Illinois 60601
(Add sheets if necessary)
| | Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in. arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ j Yes ~~J N° \~j No person directly or indirectly owns 10% or more of the Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[] Yes Q No
FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment ofany fine, fee. tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of 15
The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section H(B)(1) of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government:
have not. during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction: a violation of federal or state antitrust statutes; fraud; embezzlement; theft: forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property:
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with, committing any ofthe offenses set forth in subparagraph (b) above:
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
5. Certifications (5), (6) and (7) concern:
» the Disclosing Party;
o any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in. connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); o any "Affiliated. Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
» any responsible, official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or. with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during thc 5 years before the date of such Contractor's or Affiliated Entity's contract" or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity:
agreed or colluded with other bidders or prospective bidders, or been a party to any 'such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in subparagraph, (a) or (b) above that is a mailer of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33.E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense ofany state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to thc Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use. nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
10. [FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired
or to be hired in connection with the Matter certifications equal in form and substance to those in
Certifications (2) and (9) above and will not, without the prior written consent ofthe City, use any such
Ver.2018-1 Page 6 of 15
contractor/subconii'actor thai does not provide such certifications or that vbe Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. If the Disclosing Party is unable to certify to any ofthe above statements in this Pari 13 (Further Certifications), the Disclosing Party must explain below:
Ifthe letters "NA," the word "None," or no response appears on. the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. To the best, of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 12-month period preceding the date of this EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").
N/A
13. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, ofthe City of Chicago. For puiposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
| ] is [/] is not
a "financial institution" as defined in MCC Section 2-32-455(b).
Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."
Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates ('as defined in MCC Section. 2-32-455(b)) is a predatory lender within thc meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
] In accordance with MCC Section 2-156-1.1.0: To thc best ofthe Disclosing Party's knowledge after reasonable inquiry, does any official or employee ofthe City have a financial interest in. his oilier own name or in the name of any other person or entity in the Matter?
Yes [7] No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l). skip Items D(2) and D(3) and proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own. name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii.) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
Yes [7] No
3. If you checked "Yes" to Item D(l), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in,the Matter will be acquired by any City official or employee.
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. Ifthe Disclosing Party checks (2). the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with thc Matter voidable by the City.
. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
1 1 2. The Disclosing Party verifies that as a result of conducting the search in step (1) above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of anv and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: Ifthe Matter is federally funded, complete this Section VI. Ifthe Matter is not federally funded, proceed to Section VII. For purposes of this Section VI. tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
e award ofany federal I v fu nt
of a member of Congress, in connection with the
federally funded grant or loan, entering into any cooperative agreement, or io extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of tlie statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501 (c)(4) ofthe Internal. Revenue Code of 1986; or (ii) it is an organization described in section. 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 199 3, as am ended.
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from, all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in. writing at the outset of negotiations.
QNo
Is the Disclosing Party the Applicant?
? Yes
If "Yes." answer the three questions below:
QNo
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
? Yes
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
? Yes ? No
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 of 15
SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION Tlie Disclosing Party understands and agrees lhat:
The certifications, disclosures, and acknowledgments contained in this EDS will become part ofany contract or other agreement between the Applicant and the City in connection with thc Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution ofany contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain, duties and . obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.ci t vofchicago.org/Ethies, and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St Suite 500, Chicago, IL 6061.0, (312) 744-9660. The Disclosing Party must comply fully with this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact, may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information. Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy ofany information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract" requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
Page 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS, and all applicable Appendices, on behalf of thc Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and ail applicable Appendices, arc true, accurate and complete as of the date furnished to the City.
4137 Western LLC
(Print or type exact legal name of Disclosing Party)
By:.
(Sign here)
Azeem Khan
(Print or type name of person signing)
Managing Member - Owner
(Print or type title of person signing)
Signed and sworn to before me- on (date) Q^>, .
OFFICIAL SEAL SARA K BARNES NOTARY PUBLIC, STATE OF ILLINOIS My Commission Expires 11/15/2024
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CITY OF CHICAGO5 ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers ofthe Disclosing Paity listed in Section II.B.l.a., ifthe Disclosing Party is a corporation; all partners of the Disclosing Paity, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Parly; and (3) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
? Yes 0 No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship. .
Page 13 of 15
CITY OF CHICAGO: ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any-legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
QYes
2. Ifthe Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
L7| The Applicant is not publicly traded on any exchange.
3. If yes to (1) or (2) above, please identify below the name of each person or legal, entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Page 14 of 15
TTV
OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor"'" as defined in MCC Section. 2-92-385. That section, which, should be consulted (www.amlegal.com ), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant tliat is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-3S5(b)(l) and (2), which, prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
QYes ? No
7/j N/A - I am not an Applicant that is a ''contractor' as defined in MCC Section 2-92-385. This certification shall serve as the affidavit required by MCC Section. 2-92-385(c)(l). If you checked "no" to the above, please explain.
Page 15 of 1.5
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 4139 Western LLC
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[/] the Property Owner and Applicant
OR
? a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR
[] a legal entity with a direct or indirect right of control ofthe Applicant (see Section 11(B)(1)) State the legal name ofthe entity in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 4137 North Western Avenue
Chicago, Illinois 60618
Telephone' 312-782-1983 pax: N/A Email- 33ra@sambankslaw.com
Name of contact person: Sara Barnes - Attorney for Applicants
Federal Employer Identification No. (if you have one): ;z___:_-11__:;:
Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if applicable):
The Applicant is seeking a Zoning Map Amendment for and affecting 4137-4139 North Western Avenue.
Which City agency or department is requesting this EDS? DPD
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification. # and Contract #
Ver.2018-1 Page 1 of 15
SECTION .Fl - DISCLOSURE OE OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
I. indicate the nature ofthe Disclosing Party:
^Person [/] Limited liability company
| Publicly registered business corporation rjj Limited liability partnership
| Privately held business corporation f~J Joint venture
Sole proprietorship [~J Not-for-profit corporation
[ General partnership (Is the not-for-profit corporation also a 501 (c)(3))?
Limited partnership ? Yes | |No
Trust ? Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable
linois
3. For legal entities not organized in the State of Illinois: lias the organization, registered to do business in the State of Illinois as a foreign entity?
[H Yes ["J No L/] Organized in Illinois
B. IF TFIE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and ali directors of the entity; (ii) for not-for-profit corporations, all members, ifany, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name ¦ Title
Azeem Khan Managing Member
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. Iff none, slate "None/
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address . Percentage Interest in the Applicant
Azeem Khan 4137 North Western Avenue, Chicago, Illinois 60618 100%
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? r~J Yes / No
Does the Disclosing. Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? [~J Yes [/] No
If "yes" to either ofthe above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Does any City elected official or, to the best, ofthe Disclosing Party's knowledge after reasonable
inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in
Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party?
? Yes g No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic parlner(s) and describe the financial interest(s).
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 15
Name (indicate whether • Business Relationship io Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Sara Barnes - Law Offices of Samuel VP Banks Attorneys (Retained) S12.500 (est.)/S6,500 (paid)
221 North LaSaile Street, 38th Floor, Chicacio, Illinois 60601
(Add sheets if necessary)
| | Check here ifthe Disclosing Party has not retained, nor expects to retain, any such, persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been, declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
f-j Yes J No QNo person directly or indirectly owns 10%) or more ofthe Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
QYes [JNo
FURTHER CERTIFICATIONS
[This paragraph 1 applies only ifthe Matter is a contract being handled by theCity's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance ofany public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment ofany tax administered by the Illinois Department of Revenue.
Page 4 of 15
3. I he Disclosing Partv and. ifthe Disclosing Pariv is a legal em it v. a!! of those nersons or entities
identified in Section 11(B)(1) oflhis FDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government:
have not. during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft: forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen, property;
are not presently indicted for, or criminally or civilly charged by. a governmental entity (federal, state or local) with committing any ofthe offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and.
have not. during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local, government.
4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-1.56 (Governmental Ethics).
5. Certifications (5), (6) and (7) concern:
<= the Disclosing Party;
o any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); o any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
° any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated lintity of either thc Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or. with respect lo a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before, the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Mailer:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency ofthe federal government or ofany slate or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such, agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracls Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimnra. Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/3315-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] ofthe Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forger}', perjury, dishonesty or deceit against an officer or employee ofthe City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or lo be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
Ver.2018-1 Page 6 of 15
contractor/subcontractor that does not provide such certifications or tliat the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. Ifthe Disclosing Parly- is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Ifthe letters "NA," the word "None," or no response appears on. the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. To the best ofthe Disclosing Party's knowledge after reasonable, inquiry, the following is a complete list of all current employees ofthe Disclosing Parly who were, at any lime during the 1.2-month period preceding the date of this FDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
N/A
13. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a ¦ complete list of all gifts that the Disclosing Party has given or caused lo be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elecled or appointed official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
r~J is L/J is not
a "financial institution" as defined in MCC Section 2-32-455(b).
Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an. affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
Page 7 of 15
Vi the Disclosing Party is unable to make this pledge because it or any of its affiliates ('as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32. explain here (attach additional pages if necessary):
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge after reasonable inquiry, does any official or employee ofthe City have a financial interest in his oilier own name or in the name of any other person or entity in the Matter? .
[JJ Yes [7] No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name ofany other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively, "City Property Sale"). Compensation for property taken pursuant to'the City's eminent, domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
? Yes I/] No
3. If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature of the financial interest:
Name- Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
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CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (I) or (2) below. Ifthe Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
2. The Disclosing Party verifies that, as a. result of conducting the search in step (I) above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names ofany and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal, funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or ifthe letters "NA" or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1.995, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee ofany agency, as defined
by applicable federal law, a member of Congress, an. officer or employee of Congress, or an employee
Vcr.2018-1 Page 9 of 15
of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or io extend, continue, renew, amend, or modify any federally funded contract, grant,'loan, or cooperative agreement.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event lhat materially affects the accuracy ofthe statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1.986 but has not engaged and will not engage in. "Lobbying Activities." as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration, of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset, of negotiations.
Is the Disclosing Party the Applicant? QYes ?No
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
Yes ? No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
| | Yes ? No | [Reports not required
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
Yes ? No
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 of 1.5
SECTION Vf! - FURTHER ACICNOWIEDGMENTS AND CERTIFICATION The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part ofany contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution ofany contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line ai www.cityofchicago.oro/Ethics , and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500. Chicago, IL 6061.0, (312) 744-9660. The Disclosing Party must comply fully with this ordinance.
Ifthe City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all ofthe information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom, of Information Act request, or otherwise. By-completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. Ifthe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
Page 11. of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/sheis authorized to execute this EDS,and all applicable Appendices, on behalf ofthe Disclosing Party, and (2) warrants that all certifications and statements contained hi this EDS, and all applicable Appendices, are true, accurate and complete as ofthe date furnished to the City.
4139 Western LLC
(Print or type exact legal name of Disclosing Party) By:<
¦¦ (Sign here) Azeem Khan
(Print or type name of person signing)
Managing Member - Owner
(Print or type title of person signing)
Signed and sworn to before me on (date) 0^>. o\ .
at Cooler . County^ \jU^Ol^ (state).
V
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED C AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) amy legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015. the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if. as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers ofthe Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners ofthe Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% ownership interest in tlie Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial, officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
7] No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B.
BUILDING CODE SCOFFLAW/PROBLEM' LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to MCC Section 2-154-010. is the /Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
? Yes LJ No
2. Ifthe Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
? Yes ?^T° \/} Tne Applicant is not publicly traded on any exchange.
3. If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Page 1.4 of 1.5
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AMD AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.am legal .com), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal'or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-3S5(b')(l) and (2), which prohibit: (ijscreening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that, the Applicant has adopted a policy that includes those prohibitions.
Yes
No
J/j N/A - I am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall, serve as the affidavit required by MCC Section 2-92-385(c)(l). If you checked "no" to the above, please explain.
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