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This record contains private information, which has been redacted from public viewing.
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Type:
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Ordinance
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Status:
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Passed
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Title:
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Dedication and vacation of public way(s) in area bounded by N Ashland Ave, W Hollywood Ave, N Hermitage Ave and W Edgewater Ave
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Topic:
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ALLEY - Dedications, - ALLEY - Vacation
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Attachments:
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1. O2017-3891.pdf
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COMMERCIAL ORDINANCE WHEREAS, the City of Chicago ("City") is a home rule unit of local government pursuant to Article VII, Section 6 (a) of the 1970 constitution of the State of Illinois and, as such, may exercise any power and perform any function pertaining to its government and affairs; and WHEREAS, the properties at 1615-1633 W. Edgewater Avenue and 1614-1628 W. Hollywood Avenue are owned by MCZ Edgewater, LLC, an Illinois limited liability Company and MCZ Edgewater Exchange, LLC, an Illinois limited liability company (together, "Developer"); and WHEREAS, pursuant to a separate ordinance ("Agreement Ordinance") authorized by the City Council of the City of Chicago ("City Council"), the City and the Developer shall enter into a real estate sales agreement ("Agreement"), whereby the Developer shall acquire, remediate and thereafter convey the portion of the vacated alley ("Vacated Alley"), as set forth herein, to the City for a subsequent lease or conveyance by the City to the Chicago Park District, WHEREAS, in exchange for the remediation and transfer of the Vacated Alley to the Chicago Park District, the vacation of Vacated Alley shall be made for no compensation and is expressly conditioned on, and the Developer shall not record this ordinance ("Vacation and Dedication Ordinance") until the Developer has delivered to the City a special warranty deed ("Reconveyance Deed") for the Vacated Alley in recordable form naming the City as grantee; and WHEREAS, in the event that the Developer does not timely convey the Vacated Alley to the City in accordance with the terms of the Agreement and this Vacation and Dedication Ordinance, the City shall record the Reconveyance Deed and reacquire title to the Vacated Alley; and WHEREAS, the City Council of the City of Chicago, after due investigation and consideration, has determined that the nature and extent of the public use and the public interest to be subserved is such as to warrant the vacation of that portion of public alley, described in the following ordinance; now therefore, BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. The foregoing recitals are hereby adopted as the findings of the City Council. SECTION 2. DEDICATION: THE EAST 16.00 FEET OF THE WEST 18.00 FEET OF LOT 16 IN BLOCK 4 IN ASHLAND AVENUE AND CLARK STREET ADDITION TO EDGEWATER IN THE EAST HALF OF THE SOUTHEAST QUARTER OF SECTION 6, TOWNSHIP 40 NORTH, RANGE 14, EAST OF THE THIRD PRINCIPAL MERIDIAN, RECORDED JULY 22,1891, AS DOCUMENT NUMBER 1508281, IN COOK COUNTY, ILLINOIS, 1737 SQARE FEET, 0.04 ACRES MORE OR LESS as shaded and legally described by the words "HEREBY DEDICATED" on the plat hereto attached as Exhibit A, which drawing for greater clarity, is hereby made a part of this ordinance, be and the same is hereby dedicated and opened as public way. Page 1 VACATION: THAT PART OF THE 16 FOOT EAST-WEST PUBLIC ALLEY IN BLOCK 4 IN ASHLAND AVENUE AND CLARK STREET ADDITION TO EDGEWATER IN THE EAST HALF OF THE SOUTHEAST QUARTER OF SECTION 6, TOWNSHIP 40 NORTH, RANGE 14, EAST OF THE THIRD PRINCIPAL MERIDIAN, RECORDED JULY 22,1891, AS DOCUMENT NUMBER 1508281, LYING NORTH OF THE NORTH LINE OF LOTS 10 TO 16, INCLUSIVE, IN SAID BLOCK 4; LYING SOUTH OF THE SOUTH LINE OF LOTS 2 TO 5, INCLUSIVE, IN EDGEWATER PROPERTY ONE SUBDIVISION, A RESUBDIVISION OF PART OF SAID BLOCK 4, RECORDED JANUARY 13, 1994, AS DOCUMENT NUMBER 94046611; LYING EAST OF THE NORTHERLY EXTENSION OF THE EAST LINE OF THE WEST 18.00 FEET OF LOT 16 IN SAID BLOCK 4; AND LYING WEST OF A LINE DRAWN FROM THE NORTHEAST CORNER OF LOT 10 IN SAID BLOCK 4 TO THE SOUTHEAST CORNER OF LOT 2 IN EDGEWATER PROPERTY ONE SUBDIVISION, AFORESAID, IN COOK COUNTY, ILLINOIS, 2512 SQUARE FEET, 0.06 ACRES as shaded and legally described by the words "HEREBY VACATED" on the plat hereto attached as Exhibit B, which plat for greater clarity, is hereby made a part of this ordinance, be and the same is hereby vacated and closed, inasmuch as the same is no longer required for public use and the public interest will be subserved by such vacation. SECTION 3. The Developer acknowledges that any private sewers, appurtenances and connections within the area to be dedicated shall be abandoned, relocated or shall be maintained at the Developers expense, or established through a City Council ordinance. In the event that any sewer is abandoned, the abandonment plans must be reviewed, approved and permitted by the Department of Water Management, Sewer Design Section prior to work. It is also the developer's responsibility to lay new sewer main at Developer's sole cost and expense in the alley to be dedicated, and in accordance with plans reviewed, approved and permitted by the Department of Water Management Sewer Design Section prior to work. Acceptance of new public sewer is contingent upon submittal of as-built drawings by the Developer within 45 days of completion and departmental review. SECTION 4. The dedication for public alley herein provided for is made upon the express condition that within 180 days after the passage of this ordinance, the Developer shall deposit in the City Treasury of the City of Chicago, a sum sufficient to defray the costs of removing paving and curb returns, and constructing the dedicated public way, in accordance with the most current version of the Chicago Department of Transportation's Regulations for Opening, Repair and Construction in the Public Way and its appendices, and in accordance with the executed Duty to Build Agreement attached herein and made a part of this ordinance as Exhibit C. SECTION 5. The vacation herein provided for are made upon the express condition that within three hundred and sixty five days (365) days after the passage of this ordinance, the Developer shall file or cause to be filed for recordation with the Office of the Recorder of Deeds of Cook County, Illinois a certified copy of this ordinance, together with the plats as approved by the Acting Superintendent of Maps and Plats. SECTION 6. This ordinance shall take effect and be in force from and after its passage. The vacation and dedication shall take effect and be in force from and after recording of the approved plats. 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IZXHi B I T C
MCZ development
11/28/16
Rachel DeCorvo Coordinating Planner, LEED AP Department of Transportation Division of Project Development 30 N. LaSalle Street, Suite 500 Chicago, IL 60602-2570 PH:(312) 744-3123 FX: (312) 744-3958 Rachel.DeCorvo@citvofchicago.
In support of my current application with the Chicago Department of Transportation's Maps and Plats unit, for a dedication of my private property for a new public way, 1 hereby state that I am the applicant or the company agent for the applicant company involved in the project, and that I have the authority to agree to the below terms of the Dedication. Please initial:
I am aware that I am responsible for the construction of all public and private rights of way (streets, alleys, etc) described on the Plat of Subdivision/Dedication.
1 further understand that all rights of way (both public and private) must be built to City specifications as detailed in CDOT's Regulation for Openings, Construction and Repair in the Public Way.
Lastly, 1 understand that construction deposits will be required to assure that the work is done correctly. An inspection will be conducted by the City upon completion of the work. The City of Chicago reserves the right to require demolition and reinstallation of any facilities that are judged to be sub par or that do not adhere to the City's standards.
1636 N. Bosworth Ave., Suite C-1 | Chicago, Illinois 60642 | 773.888 9200 | www.mczdevelopment.com
Page 2 of 2
Printed name: "lL=>0>b iMoul^kJ
Organization: l/U^-'Z. &<^L>3frf&^t (^UL
Address:
Phone/fax: C3^>^2- tctolX
Email:
Date: Title:
_Zip:
Notary:
S GUTIERR£Z October 31. 201 7
.1636 N Bosworth Ave : Suite C-l | Chicago, Illinois 60642 | 773.888 9200 | www.mczdcvclopment com
Chicago Department of Transportation
CITY OF CHICAGO
05/12/17
Mr. Edward Siskel Corporation Counsel Room 600 - City Hall Chicago, IL 60602-1289
Attention: Ms. Lisa Misher
Chief Assistant Corporation Counsel
Re: Proposed Vacation for MCZ Edgewater LLC Commercial Vacation File: 06-40-16-3766
Dear Mr. Siskel:
Pursuant to a request from Mr. Todd Mullen, we are transmitting herewith for your review and approval as to form and legality an original and three (3) copies of a proposed vacation of a portion of the E-W public alley and a dedication of a new N-S public alley in the block bounded by W. Edgewater Avenue, W. Hollywood Avenue, N. Ashland Avenue and N. Hermitage Avenue. This property is located in the 40th Ward.
MCZ Edgewater LLC is the owner of record to the properties adjoining the public alley to be vacated, and the owner of record of the lot to be dedicated as a new public alley. The people to contact in connection with this proposed ordinance are Mr. Todd Mullen at 312-402-6621 and Mr. Michael Lerner at 773-888-9200.
A reservation has been made for the Department of Water Management/Sewer Section in Section 2 of the ordinance. Section 3 provides for a deposit for the required alley construction, curb and walk work. All other underground utility agencies are either not involved or have made suitable arrangements. Section 4 contains an explanation of the compensation issue. Sections 5 and 6 of the ordinance are standard language regarding the recording.
Commissioner
"Luann Hamilton Deputy Commissioner
RS: LH: RD
cc: Alderman O'Connor
Alderman Anthony Beale
SandftFoMarl/^^ Illinois 6O602
cn'vorc:iHc.\c;o economic disclosure statement and affidavit
SECTION I -- GENERAL INFORMATION
A, Legal name of the Disclosing ['any submitting this EDS. Include d-'b'a/ if applicable:
M
Check ONE of (ho following three boxes:
Indicate whether ihe Disclosing Party submitting this EDS is:
M the Applicant <£>-l\f>rUtA*\r ^/ tM^*~ dtt^o-*n£A- <»**W*J«itf ,
OR
f j a legal entity currently holding, or anticipated to hold within six months tiller Cily action on
ilie contract, transaction or other undertaking to which this: EDS pertains (referred lo below as the
"Manet"), a direct or indirect interest in excess of 7.5% in the Applicant. Stale the Applicant's legal
name: r _ _ . ...... ..... .
" OR"""~ ""
f ] a legal entity with a direct or indirect right of control of the Applicant (see Section N(B)( I )} State thc legal name, of the cmiiy in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Parly: llnyi? <0 ¦ ^^^o Cw<*tei>+Jzr. (pOfe^Z
C Telephone: 7lhfax: Eniail;T*>MVu&\ Q^(JU^^uPMeo^C tow
D. Name nf contact person: -"Top® >Muiujas)
V Federal Employer Identification No. (ifyou have one): _ ¦
Brief description of the- Matter to which this EDS pertam.s. (Include project number and locution of property, if applicable):
Mjy^l df^rs'l^lU^^LM^lrvl Which City agency or department is requesting this EDS? <2>t)aT _1
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification ••' _ _ and Contract _ ;
V'cr ?,0i 7-1 Paj;e 1 of U
SECTION It - DISCLOSURE OF OWNERSHIP INTERESTS
•V NATURE OJ- THE DISCLOSING PARTY
1. indium- thc n.nure of the Disclosing Party:
!' ] Person "PQ Limited liability company
| ] Publicly registered business corpouition | j Limited liability partnership
[ ] Privately held business corporation [ ] Joint venture
f j Sole proprietorship [ | Not-for-profit corporation
| | General partnership (Is the not-for-profit corporation also a 50 1 (e)(.1))'.'
[ | Limited partnership I I Yes | J No
f j Trust i J Other (please specify)
2. For legal entities, ihe state (or foreign country) of incorporation or organization, ii applicable:
J!£*_ ;:Ni c- _ _ _ .
3. For legal entities not organized in thc State of Illinois: Mas the organization registered to do
business in ihe Slate of Illinois ns a foreign entity?
[ j Yes [ ] No Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity: (ii) for tiot-lbr-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); ( iii) for (rusts, estates or other similar entities, the trustee; executoradministrator, or similarly situated party; (h>) 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 thc day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
J^f^h^L?...ksiM hfj£»^ ^.^M^W ._ _ _ _
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% of the 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
1\i-jc 2 ol N
iimited hahilitv ooiupauv. or interest of a beneficiary of a trust estate oj other similar enlity. If none, stale "'None.''
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf
Name Business Address Percentage Interest in ihe Applicant
ff\fMi /H-'i ».L L'S'Ahi^'. .U'vto.LL-. fe^Xafirftt _ „ ._
•VdA t^iAp^s LLC. i*J. Cui^c^ VUA'->
¦^'^^Qx^^^.A?^^v^^U^ iat£j&* b*:lg»>4 , _ £i_£» —
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 thc
12-rnonth period preceding the date of this EDS*' I ] Yes No
Does the Disclosing Party reasonably expect 10 provide any income or compensation lo any City elected official during the 12-monih period following the date of this EDS? [ | Yes No
If "yes" to either of the above, please identify below the namc(s) of such City elected officials') and describe such income or compensation:
Does any City elected official or, to the best of the Disclosmg 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 Chicauo ("MCC")) in the Disclosing Party? I] Yes p
If "yes." please identify below the nume(s) of such City elected official(s) ynd-'or spouse! s)/domestie parmer(s) and describe the financial interesi(s).
SECTION IV - DISCLOSURE OF SUBCONTRACTORS ANT) OTHER RETAINED PARTIES
The Disclosing Party must disclose ihe 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 thc Matter, as well as thc nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Parly is not required to disclose employees who are paid solely through the Disclosing Parly's regular payroll. Ifthe 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.
PayoJ of 14
Name (indicate whether Business Relaiionship io Disclosing. Party fees f i.ulicaie whether
retained or aniicipatcd Addiess (subcontractor, aliorney, p.tn! o: ^tim.qcd i NO'IT',;
tu he retained i lohbvisl. etc.) "hnwlv rale." 01 :'( b.d." is
^V'v . not an acceptable rcspor.se ,
( Add sheets if necessary)
| j Check here it"the Disclosing Party has not retained, nor expects to retain, :niy such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities thai contract with the City must remain in compliance with their child support obligations throughout the contract's icon
I las any person who directly or indirectly owns 10% or more of the Disclosing Party been declared m arrearage on any child support obligations by any Illinois court of competent jurisdiction?
( ] Yes y<$ No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.
IT "yes." has the person entered jnto a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[ J Yes J No
FURTHER CERTIFICATIONS
j This paragraph 1 applies only ifthe Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the dale of this EDS, neither the Disclosing Parly nor arty Affiliated Emily [sec definition in (5) below] has engaged, in connection with ihe performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance eonsultam (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 llteir business practices so they can be considered for agency contracts in the future, or continue with a contract m progress).
The Disclosing Party and its Affiliated Entities are not delinquent in ihe payment of any fine, fee, (ax or other source of indebtedness owed to the Cily of Chicago, including, bin not limited lo. water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is ihe Disclosing Party delinquent in the payment of any tax administered by the Illinois Depariment of Revenue.
The Disclosing Party and. if the Disclosing Paily is a legal entity, all of those persons or entities identified in Section IffBji 1) of this EDS.
are not presenile dcbaircd, suspended, proposed Uu debarment, declared ineligible or \ oluniarily excluded from any transactions by any federal, state or local unit of government.
have nol, during the 5 years before thc date of this EDS, been convicted of a criminal olfensc, adjudged guiliv. or had a civil judgment rendered against them in connection with: obtaining, allempiingio obtain, or performing a public (federal, slate or local) transaction or comract 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 t federal, stale or local) with committing any of the offenses set forth in subparagraph (b) above;
d have not. during the 5 years before thc date of this EDS. had one or more public iiansactions (federal, stale or local) terminated for cause or default; and
c. have not. during the 5 years before thc 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 2-5b (Inspector Geneial) and 2-15C> (Governmental Ethics).
Certifications (5). (6) and (7) concent:
the Disclosing Party;
« 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 '):
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 ineligibi lity 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 Parly, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 oi'14
Neither the Disclosing i'arty. nor any Contractor, nor any Affiliated Entity ofeiihci the Disclosing Party or any Conuacior, nor any Agents have, during the 5 years before the date nf this EDS. or, with respect to a Contractor, an Affiliated, llntit>, or an AiTiliated Entity of a Contractor during the 5 years before the dale of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter
bribed or attempted io bribe, or been convicted or adjudged guilty of bribery or attempting lo bribe, a public office; or employee of the Cily, (he State of Illinois, or any agency of the federal government or ol any state or local government in the E'niled States of America, in that officer's or employee's oM'icial capacity;
agreed or colluded with other bidders or prospective bidder*, 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 otherw ise: or
e. made an admission of such conduct described in subparagraph (a ) or (b) above that is a maitcrof record, but have not been prosecuted for such conduct; or
d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contr;icts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Mmimum 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 slate 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 5/3JE-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-rolaiing.
Neither ihe Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by thc United States Department of Commerce, State, or Treasury, or any successor federal agency.
[EOR APPLICANT ONLY] (t) Neither thc Applicant nor any '-controlling person" (see MCC Chapter 1 -23. Article T for applicability and defined lermsj 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 lo 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 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 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 of the City, use any such
V\:i.2017- 7 l\"iuo6 of'l-4
c:u 111racxoi. subeoiitiactor thai Joes not provide such certifications or that ihe Applicant lias reason to believe iias not piovided or cannot provide truthful certifications.
1 1. If ihe Disclosing Party is unable lo certify io any of ihe. above st.-ilcinenis in this Pan H iluithei Certifications}, the Disclosing Party must explain below:
Ifthe letters "NA," the word "None," or no response appears on the lines above, ii will be conclusively presumed thai the Disclosing Pany certified io the above statements.
1 2. To the best ofrhc Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Parly who were, at any time during the 12-montli period preceding thc date of this EDS. an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
I 3. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all .gifts that Ihe Disclosing Pany has given or caused to be given, at any Time during the 12-month period preceding the execution dare of this EDS, to an employee, or elected or appointed official, of Ihe 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 S25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicale with "N'A" or "none"). As to any gift listed below, please also list the name of ihe City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Patty certifies thai ihe Disclosing Party- (check one)
t J 'S not
a "financial institution" as defined in MCC Section 2-32-455fb).
If ihe Disclosing Party IS a financial institution, then thc Disclosing Party pledges:
"We are not ami will not become a predatory lender as defined in MCC Chapter 2-32. Wc further pledge thai 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 thc loss of the privilege of doing business with Ihe Cily."
Page 7 of 14
Ifthe Disclosing l'iiriy is unable to make this pledge because ii or any of its affiliates (as defined in MCC Sex-lion 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here fa:taeh additional-pages if necessary):
If thc letters "NA," the word "None," or no response appears on the lines above, il will be conclusively presumed that the Disclosing Party certified lo the above staieinems.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CI IY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in ;his: Pari D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Parly's knowledge after reasonable inquiry, does any official or employee of the Cily have a financial interest in his or hei own name or in thc name of any oilier person or entity in the Maiter?
[ J Yes No
NOTE: Ifyou checked "Yes" to Item D(l), proceed to Items D(2) anil Dp). !!' 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 permmcd. 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 properly that (i) belongs to the Cily. or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the 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 | | No
3. Ifyou checked "Yes" to hem D( 1), provide ihe names and business addresses of the Cily officials or employees having such financial interest and identify thc nature of (he 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.
I'aueXol'U
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (I) or (2) below. Ifthe Disclosing Parly checks i2). the Disclosing Parly must disclose below or in an attachment to this EDS all information required bv ( 2 ). failure to comply with these disclosuie requirements may make any contract entered into with ihe Citv in connection with the Matter voidable bv the Citv.
' ne Enclosing Party verifies that the Disclosing Party has searched any and all records of thc Disclosing Party and any and all predecessor entities regarding records of in\ estments or profits from slavery or slaveholder insurance policies during lite slavery,era (including insurance policies issued to slaveholders that provided coverage tor damage lo or injuiy or death of then slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step fl) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Pany verities that the following constitutes full disclosure of all such records, including the names, of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUND El) 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 nol 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 tellers "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 Patty with respect to the Matter,)
2. The Disclosing Party has not spent and will nol expend any federally appropriated funds to pay
any person or entity listed in paragraph A( 1) 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
Vcr.?.()!7-i p.lt;v; 9 0f 14
;
of a member of Congress, in connection with ii so award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or tu 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 the. .statements' and information set forth in paragraphs A(l) and Al.2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501 (c)(4) of thc Internal Revenue Code of 19So; or (it) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 19x6 but has not engaged and will not engage in "Lobbying Activities." as that term is defined in thc Lobbying Disclosure Act of 1995. as amended.
If the Disclosing Patty 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 die Disclosing Party must maintain all such subconbactors' certifications for lite duration of the Mailer and must make such certifications promptly available to the City upon request.
14. CERTIFICATION REGARDING EOUAL EMPLOY M ENT OPPORTE' NT I Y
Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the follow ing information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
1. ] Yes ' [ J No
If "Yes," answer the three questions below:
i. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CI R Part 60-2.)
| ]Yes I j No
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 ah reports due under the applicable filing requirements?
f ] Yes |" JNo . f ] Reports not required
3, Have you participated in any previous contracts oi subcontracts subject to the equal opportunity clause?
L 1 Yes (. j No
Ifyou checked "No" to question (1) or (2) above, please provide an explanation:
Ver.2017-1 I'a.ue 10 of 14
SECTION VII ~ FURTHER ACKNOWLEDGMENT S AND CERTI1 TCA HON
The Disclosing Party understands and agrees ilicit.:
Thc certifications, disclosures, and acknowledgments contained in this f.DS will become part of any contractor 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 die City's execution of any 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 wv, w.ciiyorcliic.ago.org.' 'Elhies, and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St Suite 500. Chicago, IL 60610. (312) 744-%60. The Disclosing Pany must comply fully with this ordinance.
Ifthe Cily determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which i; 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 10 allow the Disclosing Pany to participate in other Cily transactions. Remedies ai law for a false statement of material fact may include incarceration and an award to the City of treble damages. ;
it is (he City's policy lo make this document available lo (he public on its Internet site and/or upon request. Some or all of the information provided >n, and appended (o. ibis EDS may be made publicly available on the Internet, in response lo a Freedom of Information Acl 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 kepi current. In the event of changes, ihe Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If ihe Matler is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as ihe contract requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article 1 (imposing PERMANENT INELIGIBILITY fot 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.
I'.-igc )l of 14
CERTIFICATION
E'mior penally of perjury, ihe person signing he low: [)) warrants thai he/she is miihoii/.ed lo execute this EDS. and Appendices A and B (if applicable), on behalfofthe Disclosing I'aiiv, and
ftfl&2. ^OtotgvONfdlL.j / i y _ _
(Prim or «yp^."_\;^ Pany)
(/sign hcrcj ^|1010|. A^'u'+iZL- - V-~li>ir- _
(Print or type name ofperson signing.)
fM" N-/ggtA—
(Print or type title ofperson signing)
Signed and sworn to before me on (dale) t"f J[
County, 77/%fc>S (stale).
9&3fr\ OfHCtAl SfA!.
Commission expires: fO/ /x >-'<{.<'!"^<^i\t^<>"--
IVw 12 of M
CITV OF CHIC ACQ ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is lo be completed only by (a) ihe Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not lo be completed by any legal entity which lias 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 Pany" 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 Parly or any "Applicable Party" or any Spouse or Domestic Partner the:oof is related lo 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 (I) all executive officers ofthe Disclosing Party listed m Section ILB.La ifthe Disclosing Party is a corporation; all partners of (he Disclosing Party, ifthe Disclosing Party is a general partnership: all general partners and limited partners ofthe Disclosing Party, ifthe Disclosing Party is a limited partnership; all managers, managing members and memhers ofthe Disclosing Party, ifthe Disclosing Party is a limited liability company: (2) all principal officers ofthe Disclosing Pany: and (3) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means thc president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority,
Docs 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?
f ]Yes Kj No
If yes. please identify below (I) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3 ) ihe name and title of ihe 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 14
CITV OP CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX P,
BUILDING CODE SCOFFLA\\7PRORl EM i.ANDEORD 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'K. (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant
Pursuant lo MCC Section 2-154-010. is the Applicant or any Ownei identified as a building code scol'llaw or problem landlord pursuant to MCC Section 2-92-416.'
| ] Yes ]Xj No
Ifthe Applicant is a legal entity publicly traded on any exchange, is any officer or director of ihe Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
| J Yes j ] No >fv//j The Applicant is not publicly traded on any exchange.
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.
IVc 14 of 14
CU V or ("UK AGO ECONOMIC DINCEt)Sl RE STATEMENT AND AI II DA YIP
section i - general information
A. Legal name ol'rlic Disclosing Part}' submitting (his EDS. Include do j il":ipp!k\!l>ic:
<^CCf ((oiittKlfc>S t ILO _ _ _ .
Check ONE ol'tlu: following three boxes:
Indicate whether the Disclosing Parly suhiniuing 1ius EDS is:
[ ] the Applicant
OR
|><.j a legal entity currently holding, oi anticipated to hold within six months alter C ily action on the contract, transaction or other undertaking to which this EDS pertains (referred 10 below as Ihe "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. Slate ihe Applicant's; legal
"•u"^- . 'HC£~^6d&i&iS3£2L^^
OR 1
I ] a legal entity with a direct or indirect right of control ofthe Applicant (see Section 11(B)(1)) State the legal name of the. entity in which the Disclosing Party holds a right of control:
Business address ofthe Disclosing Party: __. ^ . PQuT^ij
V^:4.4^,...<4^_i£Q6iLii
Telephone: ?r*-. A^t, fax: Entail: MiV^t^ntsts0 tt\^<&frjfl4:>,t-ir>i*>
Name of contact person: ft/irt&er &cx-V>&k{'.
Federal Employer Identification No. (ifyou have one!
F Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if appl icable):
(62S- ibK> uJ - ouycOoco
G. Which City agency or department is requesting this EDS?_ S:'POT.
ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete thc following:
Specification # _ and Contract #
Vcr.2017-1 I'aiio i of 14
SECTION II -- DISCLOSURE OE OWNERSHIP INTERESTS
A. NA I URL OI THE DISCLOSING PAR! Y
1. Indicate the natuie ofthe Disclosing Party
j "| Person j[ ] Publicly registered business corporation j I Limited liability partnership
j J Privately held business corporation [ >] Join! venture
i' j Sole proprietorship f ] Not-i.or-prolit corporation
[ ] General partnership (Is the not-for-profit corporation also a 501(e)(3))?
j J Limited partnership I j Yes [ | No
[ ] Tiiim w { j Othci (please specify)
foi legal entities, the state (ot foreign country) of incorporation or organization, if applicable:
k< fa£-k__ _ ._ .
for legal entities not organized in die State of Illinois: Has ihe organization registered lo do business in the State of Illinois as a foreign entit y?
[ J Yes No [ ] Organized in Illinois
EL IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below the full names and titles, if applicable, of: (D all executive officers and all directors of Ihe entity; (ii) for not-for-profit corporations', all members, if any, 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
MtuiAei fro./Vou fU*>Jr%tfr'
/6slu/ C?tia?i&K]
2. Please pro\ ide the following information concerning each, person or legal entity having a direct or indirect, current or prospective (i.e. within 6 mouths after Cily 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
P/me 2 ni" N
limited liability company, or interest of a beneficiary of n tnisi. estate or other similar entity If none, stale "None/'
NOTE. Each legal entity listed below may be required to submit an EDS o;, j is own behalf
Name Business Address Percentage Interest in the Applicant
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SECTION III -- INCOME OU COMPENSATION TO, OK OWNERSHIP BV, CITY ELECTED OFFICIALS
Has the Disclosing Pany provided any income or compensation to any Cily elected official during the
12-month period preceding the date of this EDS'' ( j Yes J^No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month period following die daie of this EDS? | | Yes fM-iNo
If "yes" to either of thc above, please identity below the namc(s) of such City elected offieial(s) and describe such income or compensation.
Docs any City elected official or. to the best ofthe Disclosing Party's know ledge 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 Partv? |; ] Yes isIf "yes,'' please identify below the name(s) of such City elected offieiaUs i and/or spouse(s)/domestie partner(S) and describe the financial inleresi(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 Ihe lotal amount ofthe fees paid or estimated lo be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Parly's regular payroll. If ihe Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask thc City whether disclosure is required or make thc disclosure.
Vei.20i7-1
Name (indicate whether Business Relationship to Disclosing Party l ees (indicate whether
retained or anticipated Address (subconti actor, attorney. paid or estimated.) NOTE:
to be retained) lobbyist etc.) "hourly rate" or "t.b.d " is
mil an acceptable response.
(Add sheets if necessary )
Check here if the Disclosing Party has not retained, not expceis 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 contraci with the City must remain in compliance with their child support obligations throughout the contract's term,
1 las any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes [^4 I I 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 I ] No
FURTHER CERTIFICATIONS
[This paragraph I applies only ifthe Mallei is a contract being handled by ihe 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 indi\ idual or entity with legal, auditing, investigative,, or other similar skills, designated by a public agency lo 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 wilh 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 lo the City of Chicago, including, but not limited to. water and sewei 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.
I,.n;c4 otT4
The Disclosing Pany and. ifthe Disclosing Pany is a legal entity, all of those persons or entities identified in Section 11(B)(1) of this EDS.
aie not presently debarred, suspended, pioposcd foi debarment, declared ineligible or voluntarily excluded from any transactions b\ any federal, state or local unit of government;
have not, during the 5 years before thc 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 ohtain. or performing a public ('federal, stale or local) transaction or contract under a public transaction: a violation of federal or state antitrust statutes: fraud: embezzlement; thefi: forgery; bribery; falsification or destruction of records: making false staienienis, or receiving stolen properly:
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, stale or local) terminated for cause or default: and
have not, during ihe 5 years before thc date of this EDS. been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil aciion, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unil 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).
Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or .subcontractor used by ihe Disclosing Party in connection with the Matter, including but nol limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, oi is, wilb (he 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 ihe same management, ownership, or principals as the ineligible entity. With respect to Contractois, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it. or, with thc 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, agenl or employee ofthe Disclosmg Party, any Coniractor or any Affiliated Entity, acting pursuant to ihe direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
I'l.ue. 5 of 14
Neither the Disclosing Pany. nor any .('omractor. nor any Affiliate;.! Entity of cither thc Disclosing Parly or any Coniractor, nor any Agents have, during the 5 years before the dale of this fl)S. or. with respect to a Contractor, an Affiliated Emily, or an Affiliated Emily of a Contractor during the 5 years before the dale of such Coniiaclor'.s or Affiliated Entity's comma or engagement in connection with ihe Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery oi attempting to bribe, a public officer or employee ofthe City, ihe State- of Illinois, or any agency of the federal government or of any stale or local gov eminent in the I Jniicd Slates oi America, in that officer's 01 employee's official capaciiy:
agreed or colluded with other bidders or prospective bidders, or been a party lo any such agreement, or been convicted or adjudged guihy of agsceineni or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bad a fixed price or otherw ise: or
made an admission of such conduct described in subparagraph (a) or (b) above that is a matter ol record, bid have not been prosecuted for such conduct; or
d violated the provisions referenced in MCC Subsection 2-92-320(a)i4)(Conlraets Requiring a Base Wage); (a)(5)( Debarment Regulations); or (a)(6)(Mininiiim 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 stale or local government as a result of engaging, in or being convicted of (I) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-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 Pany nor any Affiliated Entity is listed on a Sanctions List maintained by thc United States Department of Commerce, Stale, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY) (i) Neither the Applicant nor any "Controlling person" [sec 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 c\er been convicted of or placed under supervision lor, any criminal offense involving actual, attempted, or conspiracy lo commit bribery, theft, fraud, forgery-perjury, dishonesty or deceit against an officer or employee ofthe Cily or any "sister agency"; iind (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.
[TOR 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 eontructors/suhconiraclors hired or ro be hired in connection with thc Manor certifications equal in form and substance 10 those in Certifications (2) and (9) above and will nol, w ithoul the prior written consent of the City, use any such
Ver.2017-1 Paize C» olT4
contractorsubcontraetor that does not provide such eenifteaiiorts or thai die Applicant has reason lo believe has not provided or cannot provide truthful cerii beat ions.
I I. I (The Disclosing Party is unable to e.erlity 10 any ofthe above statements in this Pari B (Further Certifications), ihe Disclosing Party ninsl explain below:
ifthe letters "NA," the word "None," oi no response appears on the lines above, n will be conclusively presumed thai ihe Disclosing Party certified 10 ihe above statements.
12. To the besi of ihe Disclosing Party's know ledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Parry who were, at any time during the 12-month period preceding the date of this FDS. an cinpiovve. or elected or appointed official, ofthe City of Chicaco (if none, indicate with "N'A" or "none").
I 3. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list ofall gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date 01 this FDS. to an employee, or elected or appointed official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available lo Cily employees or to the general public, or (it) food or drink provided in the course ofofficial Cily business and having a retail value of le»s 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 lis! the name ofthe Cily recipient.
E^EEzEEEE ::=:EE;zE:EEz==:
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosmg Party (check onei
{ J 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
"Wo arc not and will not become a predatory lender as deliued in MCC Chapter 2-32. Wc further pledge thai 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."
Ves.201 7-1
Ifthe Disclosing Pany is unable to make this pledge because ii ot any of its affiliates (as defined in MCC Section 2-32-455(b'j> is a predawn\ lender within thc meaning <>f MCC Chapter 2-32, explain here- ('attach additional panes if necessary):
".' :::::zz::::::::::
Ifthe letters "NA," the word "None," or no response appears, on the lines above, it will be conclusively piesumed that the Disclosing Party certified to the ahovc- statements.
D. ClilU'l! ICATION REGARDING FINANCIAL INI ERP.ST IN CITY BUSINESS
Any words or terms defined in MCC' Chapter 2-150 have the same meanings if used in this Part I).
In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge afler reasonable inquiry, does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person oi entity in the Matter ''
I | Yes t*3Nr>
NOTE: Ifyou checked "Yes" to Item D(l), proceed lo Items D(2.) and D(3). Ifyou checked "No" lo Hem DO ), skip Items D(2) and D(3) and proceed to Part E.
Unless sold puisuant 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 thc purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, oi (iii) is sold by virtue of legal process at the sun 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 Properly Sale'.'
[ | Yes ( ] No
Ifyou cheeked "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 ihe financial interest:
Name Business Address Nature of Financial Interest
4, The Disclosing Pany further certifies that no prohibited financial inteiest in the Matter will be acquired by any City official or employee.
Page 8 of t4
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
1'lease check cither (1) or (2) below I; the 1 >isck.ismi: Pany cheeks i.2). the Disclosing Pany must disclose below or in an attachment in this EDS ail 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 Cily.
1. The Disclosing Party verifies, that the Disclosing Party has .searched any and all records of ihe Disclosing Party and any and all predecessor entities legending records of investments or profits from shivery or slaveholder insurance polic ies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damnue to or in jury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies thai, 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 Parly verifies that the following constitutes full disclosure of all such records, including thc names of any 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 VIE For purposes of Ibis Section VI, tax credits allocated by the City and proceeds of debt-obligations ofthe 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. thc 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 1995. as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Mailer.)
2. The Disclosmg Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A( I) above- for his <>r 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, oi an employee
Ver.2017-1 Pas;e 9 of 14
t
of a member of Congress, in connection wilh ihe award of any federally funded contract, making any federally funded grant or loan, entering inlo any cooperative agreement. o: to extend, continue, renew, amend, or modify any federa-lly funded contract gram, loan, or coopenuue agreement.
'fhe Disclosing I'arty will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially alfcets the accuracy oi'the statements and information set forth in paragraphs A(l j and A(2) above
Thc Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) ofthe Internal Revenue Code of 19K6; or (ii) it is ait organization described in section 501(c)(4) ofthe Internal Revenue Code of 10X6 but ha-: not engaged and will not engage in "Lobbying Activities." as that term is defined in the Lobbying Disclosure Act of 190s. as amended
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs Ad J through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Parly must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the. City upon request.
H. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
Ifthe Matter is federally tunded. federal regulations require the Applicant and all proposed subcontractors to submit thc following information with their bids or in writing at the outsei of negotiations.
Is the Disclosing Party the Applicant'.'
I J Yes |. ] No
If "Y'es," answer thc three questions below:
I. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (Sec 41 CFR Pan 60-2 ) '
[ ] Yes f I No
Have you filed with the Joint Reporting Conunitiee. the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under thc applicable filing requirements?
[ J Yes [ ] No ( ] Reports not required
Have you participaleii in any previous coniiacis oi subcontracts subject lo the equal opportunity clause?
[ ] Ves I ] No
If you cheeked "No" to question (1) or (2) above, piea.se provide an explanation:
\';u.:j. ID .if N
SECTION VII --ECRI HER ACKNOtt EEIX.MEN I S AND CERTIFICATION
The Disclosing Pari)' understands and agrees ihai:
The certifications, disclosures, and acknowledgments contained in this EDS will become part, of any contract or other agreement between the Applicant and the Cily in connection w iih the Matter, whether procurement, City assistance, or other Cii;, action, and arc material inducements to the City's execution of any contract or taking other action with respect to ihe Matter, The Disclosing Party understands that il 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.eitvofchicago.ore/Ethics . and mav also be obtained from the City's Board of Ethics. 740 N. Sedgwick St., Suite 500, Chicago, IE 60610, (312) 744-9660. The Disclosing Party must comply En!iy wiih this ordinance.
If ihe City determines that any information provided in tins EDS i.-, false, incomplete or inaccurate, any contract or other agreement in connection wiih w hich 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 lo make this document available lo the public on ils Internet site and/or upon request. Some or all ofthe information provided in, and appended to. this EDS maybe made publicly available on the Internet, in response to a freedom of lnformaiion Act request, or otherwise. By completing and signing this EDS, ihe Disclosing Party waives and releases any possible rights or claims which it may have against the City m connection w ith the public release of information contained in this EDS and also authorizes the City lo verily the accuracy of any information submitted m this EDS.
The information provided in this EDS must be kept current. In the event of changes, (he Disclosing Party must supplement this EDS up to the time Ihe City takes action on the Matter. Ifthe Matter is a contract being handled by the City's Department of Procurement Sendees, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Mailers 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.
Paw II of 14
CERTIFICATION
Under penalty of perjury, die person signing below: (I i warrants that Iie'slie is authorized to execute this EDS, and Appendices A and \\ (('("applicable), on behalf of thc Disclosing Party, and (2) warrants S| that all certifications and statements contained in this EDS, and Appendices A and 8 (if applicable), tire tine, accurate and complete as ofthe date furnished to ;hc City.
(Print or type exact legal name of Disclosing Pany)
By; _ - _1" __
(Sign here)
/i/}{(~H'A&l- ty^U}&*L
(Print or type name ofperson signing)
Mkkt-kbcyl. . ._
(Print or type title ofperson signing)
Signed and swoni to before me on (dale)' JjjA..."
at \X_ >?^V- County. "\^ W\ Ao; u \ (state).
! J A-
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iSTotary Public
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ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS Va I I II ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to he 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 nut to be completed by any lcj»:»l entity which has onl\ an indirect ownership interest in Ihe Applicant.
Under MCC Section 2-154-0! 5, the Disclosing. Parly must disclose \shei her such Disclosing Pany or any "Applicable Party" or any Spouse or Domesuc Partner (hereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship'' exi.-.is if, as of the date this EDS is signed, the Disclosing Pany or any '"Applicable Party" or any Spouse or Domestic Parmer 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 -aster, 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 of the Disclosing Patty listed in Section I LB. La., ifthe Disclosing Party is a corporation; all partners ofthe Disclosing Party, if the Disclosing Party is a general partnership: all general partners and limited partners ofthe Disclosing Party, ifthe Disclosing Party is a limited partnership: all managers, managing members and members ofthe Disclosing Party, ifthe Disclosing Party is a limited liability company: (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7,5% ownership interest m 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?
If yes, please identify below (1) the name and title of such person, (2) the name ofthe 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.
l\vv 13 of 14
CITV ()l; CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCO ITT. ANN /PROBLEM LANDLORD CERTIFICATION
This Appendix, is to be completed only by (a) ihe Applicant, and (bi any legal entity which has a direct ownership inleresi in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indued ownership interest in the Applicant.
I. Pursuant lo MCC Section 2--i>l-010. is the Applicant oi any Owner identified as a building code scofflaw or problem landlord pursuant lo MCC Section 2 92-1 Id?
[ ]Yos -TYfNo
2 If ihe Applicant is a legal entity pubiiely traded on any exchange, is any officer or director of the Applicant identified as a building code scolTknv or problem landlord pursuant to MCC Section 2-92-4 Id?
| J Yes [ | No ijv/f'Thc Applicant is nol 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.
l';me 14 or' 14
CITY OI'-" CHICAGO ECONOMIC DISCLOSURE STATEMENT AND Al l I DAY I I
SECTION I - GENERAE INFORMATION
A. Legal name of the Disclosing Puily submitting this EDS. Include d/b.V if applicable:
".nieCii; E(lav.^.Jt.l.li^i^.f^.S/ LLC-:
Check ONE of the fallow ing three boxes:
Indicate whether ihe Disclosing Party submitting ibis E DS is:
[ 1 the Applicant
OR
[yj a legal entity currently holding, or anticipated to hold within six months after Cily action on
the contract, transaction or oilier undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest m excess of 7.5% in the Applicant. State the Applicant's legal
name: tA^-z- ggfagplkoai u,*-, 4- uv-2~ epygui Argu, e^oWl^g tto
OR
f | a legal entity with a direct or indirect right of control ofthe Applicant (sec Section II(B)(t)) Stale the legal name ofthe entity in which the Disclosing Party holds a right of control;
It, Business address ofthe Disclosing Pany: &l% tOu Qtffaab _ __
CJliZUXxi t X-»- liiCtjP^ I
Telephone: ¦ olcO pax: Email: -Tl^utaai&€> f^i^«ftp»?x<>an*
Name of contact person: rC5V**>. t^W^uj
\i. Federal Employer Identification No. (ifyou have one):
Brief description ofthe Matter to which this EDS pertains. (Include projcci number and location of property, if applicable): J
G, Which City agency or department is requesting this EDS? ^AixS*T
ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification << _ _ . and Contract if
SECTION 11 - DISCLOSURE OE OWNERSHIP INTERESTS
A. NATURE OE THE DISCLOSING 1'AKTY
I. indicate (he nature ofthe Disclosing Parly:
[ ] Person E>q Limited liability company
S J Publicly registered business corporation [ ] Limited liability partnership
[ ] Privately held business corporation | ] -'oim venture
[ J Sole proprietorship i j Not-for-profit corporation
[ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))?
[ J Limited partnership | j Yes [ J No
[ ] Trust. ( J Other (please specify)
2, for legal entities, (he state (or foreign country) of incorporation or organization, if applicable:
!?Lur*>iOiC=>
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 i ]Nn (^| Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTIT Y:
I. List below thc full names and titles, if applicable, of: (i) all executive officer s and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which .ire 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
J**?*±l3Llh- e^>».<^ M**&fefia.
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. Examines of such an interest include shaves in a corporation, partnership interest in a partnership or joint ve.nnue, interest of a member or manager in a
Page 2 of N
limned liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."'
NOTK: bach legal entity listed below mas he required to submit an EDS on iij, own behalf.
Name Busioess Address Percentage lnteicst in the Applicant
•tTitoruk Sbuad ic^>% _ .
¦ i
SECTION III - INCOME OK COMPENSATION TO. OR OWNERSHIP BY. CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the-
n-month period preceding the date of this EDS'? [ J Yes [SifNo
Does thc Disclosing Party reasonably expect to prov ide any income or compensation to any Cily elected official during the 12-month period following the date of this EDS? I ] Yes No
If "yes" to cifhei of ihe 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. lo the best ofthe Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest fas defined in Chapter 2-156 ofthe Municipal Code of Chicago ('"MCC"}) in ihe Disclosing Party? t 1 Yes K4No
If "yes." please identify below the naine(s) of such City elected offteial(s) aud'or spouse(s)/domestic partner(s) and describe the financial interest(s).
4*
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Parly must disclose the name and business address of each subcontraeloi. attorney , lobbyist (as defined in MCC Chaptei 2-156). accountant, consultant and any other person or entity whom ihe Disclosing Party has retained or expects lo 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 thc disclosure.
Pay,;: 3
Nairn: (indicate whether Business retained or anticipated Address to be retained)
Relationship to Disclosing Pan v. (subcontractor, attorney, lobbyist, etc )
l ees (indicalc .whether paid oi estimated.) NOPE:
"hourly rate" or ''i.b.d.' is not an acceptable response.
( Add sheets if necessary i
Check here ifthe Disclosing Pany has not retained, nor expects to retain, any such persons or entities. SECTION V - CERT It ICAHONS
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 Pany been declared in arrearage on any child support obligations by any I llinois court of competent jurisdiction?
f ] Yes ^ No [ I No person directly or indirectly owns 10% or more of thc Disclosing Pany.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is thc person in compliance with that agreement?
[ lYcs [ JNo
FURTHER CERTIFICATIONS
1. [Tins paragraph 1 applies only ifthe Matter is a contract being handled by the City's Department of
Procurement Services.} In the 5-year period preceding thc 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 moniior. independent priv ate sector
inspector general, or integrity compliance eonsuhant (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 specilicd agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in thc future, or continue with a contract in progress).
2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine. fee.
or other source of indebtedness owed to the City of Chicago, including, but nol 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 ofRevemtc.
I'aue4 of 14
.V The Disclosing Pain and. ii'iiio Disclosing P;.n v is j legal eniii\. al! oi'ihosc persons or entities identified in Section )UB ){! < oi litis l .l )S'
are not presently dc.bai red. suspended, proposed tor 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 dale of this EDS, been convicted of a criminal offense, adjudged guilty, or had a ci\ il judgment reiulered against litem in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contiacl under a public transaction; a violation .of federal or state auiitrust statutes; fraud; embezzlement; theii: foreery: bribery: falsification or destruction of reeoids: making false statements: or receiving stolen property;
c are not presently indicted for, or criminally or civilly charged by. a govern menial entity (fedeial. State or local) with committing any of the offenses ,sci forth in subparagraph (b) above;
have not. during the 5 year-; beiore the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause 01 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 (he City or by the federal government, any state, or anv 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).
Certifications (5), (6) and (7) concern.
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Pany in connection with thc Matter, including but not limited to all persons or legal entities disclosed under Section IV. "Disclosure of Subconiiaciors and Other Retained Parties"):
any "Affiliated Entity" (meaning a person or entity that, directly oi indirectly; controls the Disclosing Party, is controlled by (he Disclosing Party, or is, with (he 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 thc 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 ol 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 Emily, acting pursuant to the direction or auihori/aiion of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
I'.i-.v 5 ol 14
Neither rhe Disclosing Pany. nor any Contactor, nor any A! filiated Emily of either ihe Disclosing Parry or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Coniraeloi. an Afliliaied Euliiy, or an Affiliated Jinlity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Pnliiy's comrnct or engagement in conneciiim with the Matter:
bribed or attempted to bribe, or been convicicd or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State ofl llinois. 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 capaciiy,
agreed or colluded with other biddcis or prospective bidders, or been a party to any such agreement, or been com ieied 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 thai is a matter of record, but have not been prosecuted for such conduct: or
violated the provisions referenced in MCC Subsecf.on 2-y2-320(.a)(4 KXajntiacls Requiring a Base Wage): (a)(5)(Debarmeivt Regulations), or (a)(6)(Minimum Wage Ordinance).
6, Neither the Disclosing Parly, 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 72b ILCS 5/33E-3: (2)
bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United
Stales of America thai contains the same elements as (he offense of bid-rigging or bid-rotafing.
7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions Lisi maintained by the
United States Department of Commerce, State, or Treasury, or any .successor federal agency.
f>. [FOR. APPLICANT ONLY] (i) Neither the Applicant nor any "contioiling person" [see MCC Chapter 1-23, Article 1 for applicability and defined terms] ofthe Applicant is currently indicied or charged with, or has admitted gtiili of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy io commit bribery, theft, fraud, forgery, perjury, dishonesty or dceeii against an officer or employee of the Cily or any "sister agency"; and (ii) the Applicant understands and acknowledges thai compliance with Article 1 is a continuing requirement for'doing business with the Cily, NOTE: If MCC Chapter i -23. Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V,
9. [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 lor Award Management ("SAM")
If). [FOR APPLICANT ONLY] The Applicant will obtain from any contractors.subcontractors hired or to be hired in connection wiih the Mailer certifications equal m form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent ofthe City, use any such
Vcr.2017-1 Paged of 14
conjiaciorsulxainiracioi thru does nol provide such certifications or thai ihe Applicant lias reason in believe lias nol. provided or cannot piovide tiulb.iul certifications.
II. l! thc Disclosing Party is unable to certify to any of ihe above statement' it; ihis Part 13 (I'nrther Certifications';, the Disclosing I'artv imis: cxolaiu below .
Ifthe letters "NA,'' the word "None," or no response appears on the lines above, it will be conclusively presumed that ihe Disclosing Party certified to the above statements.
12. To the best of ihe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of thc Disclosing Party who were, at any lime during the I 2-montli period preceding the date of this FDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N7A'' or "none").
— : zzz::=:_:_7^=iii
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 litis EDS. lo an employee, or elected or appointed official, ofthe Cily of Chicago. For purposes of (his statement, a "gift" does not include: (i) anything made generally available lo City employees or lo the general public, or (ii) food or drink provided in (he course of official Cily 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 wiih "N'/'A" or "none"). As to anygifi listed below, please also list the name of the Cily recipient.
_ _
C. CERTIFICATION OP STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies thai ihe Disclosing Parly (check one)
| J is £Vf is not
a "financial institution" as defined in MCC Section 2-32-455(b).
Ifthe Disclosing Pany IS a financial institution, then the Disclosing Pany 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 w ill 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 (he City."
Ver.2017-1
If the Disclosing Party is unable lo make this pledge beeause it or any of its affiliates ;:r:::::;. zizi:. i::
Ifthe letters "NA." the word "None." ornu response appears: on the lines above, it v. ill be conclusively presumed that the Disclosing Party certified to the above slaiemenis
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 10: To the best ofthe Disclosing Party's knowledge after reasonable inquiry, does any official or employee ofthe City have a financial interest in his or her own name or in (he name of any other person or entity in the Matter?
[ ]Yes fc£No
NOTE: Ifyou checked "Yes" to Item D(l), proceed to Items D(2) and D(3). Ifyou checked "No" to Item D(T), skip Items D(2) and D(3j and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otheiwisc 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 thai (i) belongs to the Cily. or (ii) is sold for taxes or assessments, or (iii l 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 Ihe Matter involve a City Property Sale?
[ ] Yes I i No
Ifyou checked "Yes" to Item D( 1), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature ofthe financial interest:
Name Business Address Nature of Financial Interest
4. Thc Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
Vci.201?-) I'fl!.'.e X of t4
I:. CEKTIFICA'ITON REGARDING SLAVER V E!
Please check eilherf I i oi (2) below. 11'the Disclosing Pany checks (2), the Disclosing. Party must disclose below or in an attachment to this LOS 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 b> the Cily.
/C L The Disclosure Pattv verifies that the Disclosiim Panv has searched anv 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.
2. The Disclosing Party verifies thai, 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 of any and all slaves or slaveholders described in those records;
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: Ifthe Matter is federally funded, complete (his 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 ofthe 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 1095, 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 Pany means that NO persons or entities registered under the Lobbying Disclosure Act of 1995, as amended, have made lobbying contacts on behalf ofthe Disclosing Pany wiih respect to the Matter.)
2. The Disclosing Parly has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A( I) 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 ageiiev, as defined
b}' applicable, federal law. a member of Congress, an officer or employee of Congress, or an employee
Ver.2017-1 Pago « of 14
of a member of Congress, in connection with (he award oi any federally funded contract, making any .federally funded granl or loan, eniering into any coopei alive agreement, or 10 extend, continue, renew, amend, or modif'v any federally funded contrael. gran!, loan, of cooperative agreement.
.v The Disclosing Party will submit an updated eerlificaiion at (he end of each calendar quarter in which, there occurs any even' thai materially affects the accuracy ol the statements and inlormation set. forth in paragraphs Ai 11 and A(2) above.
The Disclosing Pany certifies thai eiiher: (i) it is not an organization described in section 501(c)(4) ofthe Interna! Revenue (.'ode of 1986; or(ii) n is an organization described in section 501(c)(4) of (he Internal Revenue Code of 19X6 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the I obbying Disclosure Act of 1995. as amended.
If the Disclosing Parly is ihe Applicant, the Disclosing. Party must obtain certifications equal in fonn and substance to paragraphs A( \ ) through A(4) above from all subcontractors before it awards any subcontract and ihe Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.
H. CERTIFICATION REGARDING EOUAl. EMPLOYMENT OPPORTUNITY
Ifthe Matter is federally funded, federal regulations require the- Applicant and all proposed subcontractors to submit (he following information with their bids or in writing at the outset of negotiations.
Is thc Disclosiim Partv the Applicant? L ] Yes ' ' [ ] 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 Pan 00-2.)
[ ] Yes f j No
Have you filed wiih 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?
[ J Yes f J No | ] Reports not required
Have you participaleii in any previous contracts or subcontracts subject to the equal opportunity clause?
[ 1 Yes [ j No
ff you checked "No" lo question (1) oi (2) above, please provide an explanation:
P.-ige Kl o(M4
ECRTTIEk A ("KNOW CEIK .".MEN I S AND CEBITLIGATION
The Disclosing Party undo stands and agrees thai".
Thc certifications, disclosures, and acknowledgments cunlamed in this EDS will become pan of any contract or other agreement between the Applicant and ihe City in connection with the Matter, whethei procurement, City assistance, or other City action, and arc material inducements to ihe City's execution of any contract or Lik ing other action with respect to the Matier. The Disclosing Party understands that it must .-comply with all skv.nics. ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-(56, imposes certain duties and obligations on persons or entities seeking Cily contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.ciiyofclhcago.org/Jithics , and may also be obtained from the City's Hoard of Ethics. 740 N. Sedgwick Si., Suiie 500. Chicago. IL 60610, (312) 744-0660. The Disclosing Patty 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 Cily may pursue any remedies under the contract or agreement (if nol rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and'or declining to allow ihe Disclosing Pany to participate in other City transactions. Remedies at law for a false .statement oi'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 io 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 '.espouse 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 Cily to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kepi current. In the event of changes, the Disclosing Party must supplement this EDS up to the lime the City takes action on the Matter, Ifthe Mailer is a contract being handled by ihe City's Department of Procurement Serv ices, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Mailers 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 ionger period, as required by MCC Chapter 1-23 and Section 2-154-020. '
I'.r.V IT 0.1 14
CERTIFICATION
Under penally of perjury, die person shinny: below: (I s warrant tlmt be/sbe is authorized lo execute Ibis FT)S. and Appendix es A and B (if applicable), on bebaif of liie Disclosing Party, and i'2) wartanls that ail certifications and statements eoriiained in this EOS. and Appendices A and B (if applicable), are true, accurate and complete as of the date furnished to die City.
-fk&C* Ctnr&V( ^oa.Vt^^ ;-LL% v
(Print or type exatjjej^ihiiuue of Disclosing Party)
By: _ (fSv. rX7 ~_
rCti^..i}J Qticcu. —
(Print or type name ofperson signing)
iv? M b&&f\,
(Print or type title of person signing)
Signed and sworn lo before me on (date) _J—L/- J
Commission expires: / j/1 . v . .:'
l'a;-e 12 of 14
CITY 01 CHICAGO ECONOMIC DISCLOSURE STATEMEM AND AFFIDAVIT
APPENDIX. A
FAMILIAL KELAHONSHIPS WIT H ELECTED CXI Y OFFICIALS AND 0EPAETM ENT HFADS
This Appendix iv (n lie completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in (he Applicant exceeding 7.5%, If is not to be completed b\ any legal entity which has only an indirect ownership interest in (he Applicant.
Under MCC" Section 2-154-015. the Disclosing Pany must disclose whether such Disclosing Party or any "Applicable Party" oi 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, ihe Disclosing Parly or any "Applicable Party" or any Spouse, or Domestic Partner thereof is iclaicd to the mayor, any alderman, the city clerk, thc 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 (I) all executive officers ofthe Disclosing Party listed in Section 11.14. La., ifthe Disclosing Party is a corporation: all partners of the Disclosing Party, il' ihe Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, ifthe Disclosing Party is a Juniied partnership; all managers, managing members and members ofthe Disclosing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Parly; and (?) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means thc 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?
I ] Yes [X_3.No
If yes, please identify below (I) the name and title of such person, (2) (he name ofthe legal entity to which such person is connected; (.}) the name and title ofthe elected city official or department head (o whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page L? of 14
CITY OF CHICAGO ECONOMIC DISCLOSURE STAT EMENT AND AFFIDAVIT
APPENDIX P>
BUILDING ( ODE SCOFFLAVvVPItOBLEM LANDLORD CERTIFICATION
This Appendix is id be completed only by (a) ihe 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 bvanv legal entity winch has only an indirect ownctship interest in the Applicant.
Pursuant m MCC' Section 2-154-010. is the Applicant or any Owner identified as a building code seoi'Jlaw or problem landlord pursuant to MCC Section 2-92-4 16?
f J Yes l>I {The Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofilaw or piohlem landlord pursuant to MCC Section 2-92-410?
| ] Yes I (No fj
.V If yes to 11) 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.
Piiee 14 <>! 14
CITY OI- CHICAGO ECONOMIC DISCLOSURE S I'ATEM ENT AND AFFIDAVIT
SECTION I ~ (GENERAL INFORMATION.
A. Legal name of me Disclosing Pany submitting this EDS. Include d/b'a/ if applicable;
JAc. zi£b*&.^M.&La^-^j^.^uu:^ _ _ _
Check ONE ofthe following intce bo ves:
Indicate whether thc Disclosing Pany submitiing this EDS is:
the Applicant —9 •¦fitcUfutoiK -o/ «UC7- 2. | | a legal entity currently holding, or anticipated to hold within six months after OTy action on the contract, transaction or other undertaking lo which this EDS pertains (referred lo below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Appliec.nl , Stale the Applicant's legal
name; _ _
OR
i. f j a legal entity with a direct or indirect right of control ofthe Applicant (see Section IRBjtl)) Slate the legal name ofthe entity in which the Disclosing Parly holds a right of control:
B. Business address of the Disclosing Party: {kMo m- figM^ctcrvF-
Telephone: 77j> - Fax: Emai 1; 1*tuuluckV?MLlQ&Jt&^AMtg\jroau
Name of contact person: ^(/>jr> i-M 11 *l
Federal Employer Identification No. (if you have one):
Brief description ofthe Mailer tjoyvhieh this EDS pertains. (Include project number and location of property, if applicable): ,g$J*A°
Which City agency or department is requesting this EDS? of j,
If thc Matter is a contract being handled by the City's Department of Procurement Services, please complete the following;
Specification /' _ _ and Contract 4
Vcr.201 7-1 I'.ige 1 oi 14
SECTION II - DISCLOSURE OK OWNERSHIP INTERESTS
A. NATURE of THE DISCLOSING PA RTA'
[ ] Privately held business corporation
[ ] Sole proprietorship
j ] General partnership
j' j Limited partnership
j } Trust
b/Q Limited iiabiliiv company
] Limned liability partnership | j Joint venture | j Not-Eoi-profit corporation (Is ihe nol-for-profu corporation also a 501(c)(3))';'
1. ) Yes j | No
j j Other tplease specify)
Eor legal entities, the state (or foreign country) of incorporation or organization, if applicable:
«3"- _ _
For legal entities nol organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[ ] Yes | ! No fXl Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. 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, if any, 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 orjoint ventures, each general partner, managing member, manuger 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
ttJtg&S.ffeSU. ftc^fctatrablste , LLCs So<_g M6VK^gU.
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 tn a corporation, partnership interest in a partnership orjoint venture, interest of a member or manager in a
Pajie 2 of 14
limited liability company, or interest of a hcnclicsury of u trust, estate or oilier similar cribiy. II' none, suite "N'one "
NO I I; bach legal entity listed below may be required m submit an EDS on its own behalf
Name Business Address Percentage Interesi in the Applicant
^...^^lA*^^ i:!:U , uV^lO • foufoiJ
-"AfMcfU _fht3AfilS T2> jrioLj^M^?, C.s ^ .Cft .f^AfeCCi - -
AkC^^^- >•}• ,<S&>- KJ . BcXK^iiOTTj;-
SECTION 1U — INCOME OR COMPENSATION T O, OR OWNERSHIP BY. CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during ibe
12-month period preceding ihe date of this EDS'.' [ ] Yes (X] No
Docs 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 officials) and describe such income or compensation:
. _ ' .
Does any City elected official or, to the best ofthe Disclosing Party's knowledge alier reasonable
inquiry, any Cily elected official's spouse or domestic partner, have a financial interest (as defined in
Chaptei 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosiim Party?
[ j Yes b<] No
If "yes," please identify below the name(s) of such City elected official! s) and/or spouscrsi.domestie partncr(s) and describe Ihe financial iniercsl(x).
SECTION IV - DISCLOSURE OF SUBCONTRACT ORS AND OTHER RETAINED PART IES
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 Mailer, as well as Ihe nature ofthe relationship, and the total amount of (he fees paid or estimated lo be paid. The Disclosing Parly is nol required lo disclose employees who are paid solely through ihe Disclosing Party's regular payroll. If ihe Disclosing Cany 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.
l'ri;v .t ol'H
Name- (indicate whether Business Relationship m 1 >isr!(tsiny. Pany Fees (indicate whether
retained or anticipated Adv.ii '^s> I'suheuiuracior. attorney, paid or estimated.) NOTE:
in be retained) lobbyist. etc.) "hum!y rue'' oi "l.b.d " is
^'3^' . no! aii acceptable response.
^^^^^ s^cct\^fitf£S^ ^'^...^oo
(Add sheets it"necessary)
| } Check' here if the Pisdosing Party has no; retained, nor expects 10 retain, any stick persons or entities SECTION V - CER 1 HTCA HONS
COURT-ORDEREIXCHIEU SUPPORT C< )VIPEIANCE
Under MCC' Section 2-^2-41 5, substantial owneis of business entities that contract with the Cily inns! remain in compliance with their child support obligations throughout the contract's term.
Mas any person who directly or indirectly owns 10% or mote ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent iuusdiction'.'
| ] Yes p^j No [ ] No person directly or indirectly owns 10%> or more of the Disclosing Party.
If "Yes." has (he person entered into a court-approved agreement for paymenr of all support owed and is the person in compliance with that agreement0
f j Yes j ] No
FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Serv ices.) In the 5-year period preceding ihe date of this EDS. neither ihe Disclosing Party nor any Affiliated Entity [see definition in (5) belowj has engaged, in connection with ihe 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).
Thc 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 Cily of Chicago, including, but not limited to. water and sewer charges, license fees, paiking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent, in the payment of any tax adininisiered by the Illinois Department of Revenue.
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3 The- 1 disclosing Party and. ifthe Disclosing 1'any \> a legal entiiy. all of those persons or entities idoiiiilied in Section iIi Ii)( 1 i of i his EPS:
are noi presently debarred, suspended, proposed fin debarment, declared ineligible or voluntarily excluded from any transactions by any federal, stale or local unit of government:
have not. during ihe 5 yeais before the dale of this HPS. been convicted of a criminal offense, adjudged guilty., or had a civil judgment rendered against them in connection with: obtaining, aueniiMiug to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction: a violation of federal or state aniiirust statutes: fraud; embezzlement; theft: forgery: bribery; falsification or destruction of records; making false slatcrneiils: or receiv ing stolen properly;
are not presently indicted for. oi criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagiaph (h) 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 dale of this HPS. 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 Cily 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),
Certifications (5). (6) and (7) concern:
ihe Disclosing Party:
any "Contractor" (meaning any contractor or subcontmctor used by ihe Disclosing Party in connection with the Mailer, including but not limited to all persons or legal entities disclosed under Section I V, "'Disclosure of Subcontractors and Other Retained Parties'');
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 thc 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 Emily means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or. with (he Contractor, is under common control of another person or entity:
any responsible official ofthe Disclosing Party, any Conductor or any At filiated Emily or any other official, agent or employee ofthe Disclosing Parly, any Contractor or any Affiliated Eniiiy. acting pursuant to Ihe direction or aulhqrizaiion of a icsponsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 ii.' N
Neiilk-i the Disclosing Pany. nor any ('onir.ictor. nor any Affiliaicd Filths of cahci thc Disclosing Party or any Contractor, nor any Agents have, during the 5 years before '.he «.!>.< c of'.his EDS. or. wiih respeei 10 a Conlraetor, an Affiliated Emily, or an Affiliated Entiiy of a Contractor during ihe 5 years before ihe dale oi such < on'rac'tor's .jr Afliliated Entity's conlraei or engagement in eonneeiion wiih the Matter.
bribed or atteinpicd 10 bribe, or been convicted or adjudged nuilty of bribery or attempting lo bribe, a public officer or employee ofthe City, the State of Illinois, or any ngencv of lite federal govenuneiu or of any stave or local government in the United States oi" America, in thai officer's or employee's official capacity:
agreed or colluded wiih 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 oi"ireedom ol 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 MC C Subsection 2-92-320(a)(4 )(Contracts Requiring a Base Wage); (n)(5j(Doharmcni Regulations); or (a)(6)(.Minirnum 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 unii of state or local government as a result of engaging in or being convicted of (I) bid-rigging in violation of 720 ILCS 5/33 E-3; C2) bid-rotating in violation of 720 ILCS 5.33E-4; or (3) any similar offense of any state or ofthe 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 Entiiy 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 ihe Applicant nor any "controlling person" [tgee MCC Chapter 1-23. Article 1 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, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any "sister agency": and (ii) thc 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.
[POR APPLICANT ONLYJ The Applicant and its Affiliated Entities will not use. nor permit their subcontractors to use. any facility listed as having an aelivc exclusion by thc U.S. EPA on live federal System for Award Management ("SAM").
[FOR APPLICA'N 1 ONLY) The Applicant will obtain from any contractors/subcontractors hired or to be hired in eonneeiion 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 Cily, use any such
Vei.201 7-1 t'w^e 6Of 14
contractor/subcontractor that does nol provide such certifications or thai the Applicant has. reason to believe has not provided or cannot ptovidc truthful certifications
11. If Ihe Disclosing I'any is unable to certify to any of ihe above statements m this Part H (Further Certifications), the disclosing Party must explain below.
Ifthe letters "N.A." die word "None." or no response appears on the lines above, ii will be conclusively presumed thai ihe I b .elosing Parly certified to the above statements.
12 .To the best ofthe Disclosing Party's knowledge after reasonable inquiry, thc following is a complete list of all current employees ofthe Disclosing Pany who were, at any time during the 12-monih period pieecdmg the date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none').
zi|:r±_:.::::::...:...:zzi::~~"zj :_;„:;i„
13. To thc best ofthe Disclosing Party's knowledge after reasonable inquiry, thc following is a complete list of all gifis that Die Disclosing Party has given or caused to be given, at any time during thc 12-month period preceding the execution dale of this EDS, to an employee, or elected or appointed official, ofthe City of Chicago, for purposes ofthis statement, a "gift" docs not include: (i) anything made gencrally'available lo City employees or 10 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 ofthe City recipient.
C. CERTIFICATION Of STATUS AS FINANCIAL INSTITUTION
1, Thc Disclosing Parly certifies that thc Disclosing Party (check one)
I 1 's "Kj's 1101
a "financial institution" as defined in MCC Section 2-32-455(b),
2. If ihe Disclosing Pany IS a financial institution, then the Disclosing. Party pledge.-.:
"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 thai becoming a predatory lender or becoming an affilialc of a predatory lender may result in ihe loss ofthe privilege of doing business with the Citv."
Paw 7 .>!'U
If die Disclosing Pany is unable to make Ibis pledge because il or any ol'iis a Hi bales (as ilelined in .VI(.'(.' Secooi) 2-32-455(1))') is a predaioiy lender u ilhin (he lr.eaning of MCC Chapter 2- 32. explain here (attach additional pages if necessary):
i ^^siii - i'i-i ' r i...z 11... 111
Ifihe tetters "N!A," the word "None." or no response appears on the lines above, if will be conclusively presumed ib;u the Disclosing Party certified to the above statements.
D. CEIU'IITCATION REGARDING FINANCIAL INTEREST IN C1T V BUSINESS
Any w ords or terms defined in MCC Chapter 2-156 have the same meanings i f used in this Part D.
In accordance with MCC Section 2-156-110: I o the best ofthe Disclosing Parly's knowledge after reasonable inquiry, does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter.'
I ! Yes i^fNo
NOTE. Ifyou checked "Yes" to Item D(h. proceed to Items D(2| and D(3). Ifyou checked "No" to Item D( 1). skip Kerns 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 of any other person or entity in the purchase of any property thai (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process ai the suit of (he Cily (collectively. "Cuy 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 thc Matter involve a City Property Sale?
[ ] Yes [ J No
Ifyou checked "Yes" lo Item D(l). provide the names and business addresses ofthe City officials or employees having such financial interest and identify thc nature of the financial interest:
Name Business Address Nature of Financial Interest
4. The Dise'iosing Party further certifies thai no prohibited financial interest in the Matter will be acquired by any City official or employee.
I'atk- X oi 14
E. CER fllTCAT'fON REGARDING SLAVERY ERA BUSINESS
Please check either (I) or (2 j below. II' the Disclosing Parly checks (.?'), ihe Disclosing Parly must disclose below or in an auaehrneni 10 ibis EDS all information required by (2). Endure to comply with these disclosure requirements may make any conliaei colored into vv ilh ihe Chy m connection \s i!h the Matter voidable by Ihe ('ily.
1. Thc Disclosing Party verifies that the Disclosing Parly has searched any and all re.cori.is of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the shivery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury- or death of their slaves ), and the Disclosing Pany has found no such records.
2. Thc Disclosing Parly verifies lhal, as a result of conducting the search in step (I) above, the
Disclosing Parly lias 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 ihe names of any 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 VIE For purposes of this Section VI. tax credits allocated by the City and proceeds of debt obligations of Ihe City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
I. List below the names of all persons* or endues registered under ihe federal Lobbying Disclosure Act of N95, as amended, who have made lobbying contacts on behalf of ihe Disclosing Parly wiih respect to the Mailer: (Add sheets if necessary).
(If no explanation appears or begins on Ihe lines above, or ifthe letters "NA" or ifthe word "None" appear, it will be conclusively presumed ihat thc Disclosing Party means that NO persons oi entities registered under (lie Lobbying Disclosure Act of I W5,,as amended, have made lobbying contacts on behalf of ihe Disclosing Parly 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( 1) above for his or her lobbying activities or to pay any
person or entiiy lo 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
Va.20T7-l Paij.c <* ufO
oi a membei of < 'ongress. in connection with the award of any fcdeiallv funded contract, inakinu any federally funded cram or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modiiy any federally funded contract, grant, loan, oi cooperative agreement.
The Disclosing Party w ill submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy oiThe statements and information set forth in paragraphs AM) and All) above.
The Disclosing Party certifies that either; (i) it is not an organization described in section 501(c)(4) of ihe Julernal Revenue Code of 19X6; or(ii) il is an organization described in section 501(c)(4) ofthe Intenral Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as thai term is defined in the Lobbying Disclosure Act of 1995, as amended.
s Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l j through A(4) above from all subcontractors before ii awards any .subcontract and ihe Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Mailer and must make such certifications promptly available lo the City upon request.
B. CERT1EICA 1TON REGARDING LQL'AL EMPLOYMENT OPPORTUNITY
Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors lo submit the following information with their bids or in writing at the outset of negotiations.
Is ihe Disclosing Party the Applicant ?
I 1 Ves " f J No
if "Yes," answer the ihree questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (Sec 41 CER Part 60-2.)
| ] Yes [jNo
Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or the Equal Employment Oppoitunity Commission all reports due under thc applicable tiling requirements?
[ ] Yes | | No | ] Reports not required
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
Ifyou cheeked "No" to question (!) or (2) above, please provide an explanation:
V-.njy t(1 of M
SECTION VII - IT i RT 11E R A C K N O \V I. E DOM E NT S AND CERTIFICATION
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this liDS will become pan oi any conliad or othei agreement between the Applicant and the City in connection with the Mattel', whether piocuremenl. City assistance, or othei City action, and are material inducements io ihe City's execution of any contract or taking other action with respect to (lie Matter. The Disclosing Party understands that it must comply wiih ail statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental E.liucs Ordinance. MCC Chapter 2-i5o. imposes certain duties and obligations on persons or entities seeking Cily contracts, work, business, or transactions. The lull text oflhis ordinance and a training program is available on line at www.eiivorchicago.org/Eihics , and may also be obtained from the City's Hoard of Ethics, 740 N. Sedgwick St., Suite 500. Chicago, IL 606III. (312) 744-9600. The Disclosing Pany must comply fully with this ordinance.
( '. if tlte Cily 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 n false statement of material fact may include incarceration and an award to the City of treble damages.
Ti is the City's policy lo make this document available to the public on iis 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 if 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 (his EDS.
The information provided in this EDS must be kept current. In Ihe event of changes, the Disclosing Parly must supplement ibis EDS up to the time the City takes action on the Mailer. Ifthe Matter is a contract being handled by the City's Department of Procurement Services, thc Disclosing Parly must update this EDS as thc contract requires. NOTE: With respect io Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INKLFCrlBIHTY.for certain specified offenses), the information provided herein regarding eligibility must be kepi current for a longer period, as required hy MCC Chapter 1-23 and Section 2-i 54-020.
P.ijic 11 of 14
( EKTTKK AT ION
Under penalty of perjury, the pcison signing below: ( I) warrants thai lie/she is authorized lo execute thi.s I DN. and Appendices A and B (inapplicable'), on hohalf ofthe Disclosing Paris', and (?) warrants (hat ail cei li fications and statenieiits contained in this. HDS, and Appendices A and li (if applicable), are true, accurate and complete as ofthe dale furnished to the. Citv.
iffiic of Disclosiim Party)
(Prim or type name ofperson signing)
(Print or type title ofperson signing)
Signed and sworn to before me on (date) f") f [/
at 1_.£L-1'1. ._. County, A ^.( ,r^OL\ (state).
Notary Public )j
Commission expires: /(j/ jy/ 7
J'.-iee 12 el'14
CIT\ OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AEEJDAVIT
APPENDIX A
I AMU IM. RELATIONSHIPS \\ ITU ELECTED CITY OEEKTALS ANT) DLP ARTMENT HEADS
T liis Appendix is to bo completed only by (a) the Applicant, and (hi any legal entity which has a
direct ownership interest in the Applicant exceedi'n» 7.5%. It is not to be completed by any legal
entity which has 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, ihe 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 slepdaughier. stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (I} all executive officers ofthe Disclosing Party listed in Section LLB.La., if the Disclosing Party is a corporation; all partners oftlie Disclosing Parly, ifthe Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, ifthe Disclosing Party is a limited partnership; all managers, managing membeis and members ofthe Disclosing Party, ifthe Disclosing Party is a limited liability company: (2) all principal officers ofthe 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, executiv e 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 )<^No
If yes, please identify below (1) the name and title of such person. (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected cily official or department head lo whom such person has a lamilial relationship, and (4) the precise nature of such familial relationship.
!',imc Is ol 14
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
AITFNDLX It
HUII.DING CODE SCOFFLAW/i'ROBLEM I ,ANL)LORD CERTIFICATION
This Appendix is to be completed only by (a.) the Applicant, and (h) any lesiid eniity winch has a diiect ownership intercsi in the Applicant exceeding 7.5"... (an "Owner). It is not 10 be completed bv anv legal entity which has only an indirect ownership interest in. the Applicant.
riiiv.ianl to MCC Section 2-1 5*4-011). is the Applicant or any Owner identified as a building code scolilaw or problem landlord pursuant, io MCC Section 2-92-4 10?
i I Yes ViN"
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 2-92-4 !o:1
| j Yes [ JNo h<3 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 entiiy identified as a building code scofflaw or problem landlord and. the address of each building or buildings to which the pertinent code violations apply.
I'aj'.c 14 i' 14
(T'J'V Or CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SI ( ITON 1 — GENERAL INFORMATION
Legal name oIThe Disclosing Pany submitting this EDS. Include d/b/a' if applicable.
. i-?J<: '2>>f. A^^.s^^rV^A/J:.../..U_ .^ ._. _ ...
Cheek ONE of the following three boxes:
indic ate whether the Disclosing Party submitting this EDS is:
j | the Applicant
OR
i,ejj a legal entiiy currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking lo which this EDS pertains (referred io below as the
"Mailer"), a direct or indirect interest in excess of 7.5% in ihe Applicant. Stole the Applicant's legal
name: cj.cz ^»goJtftrgft. tSyptAajke. i jlX^.
OR
| ] a legal entity with a direct or indirect right of control ofthe Applicant (see Section 11(B)(1)) Slate the legal name ofthe entity in which the Disclosing Party holds a right of control:
Business address ofthe Disclosing Party: Uj^u M . tx>*KA>fl.n-t- ._
Telephone: 77» .Name of contact person: ^T^Vs tM\/a>£Al _• - -
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):
t
Which City agency or department is requesting this EDS'? ^)J^1._.„.
lfthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification« _ _ and Contract fl _
Vei.2'M7-I 1 ut 14
SECTION Jl - DISCLOSURE OE OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Indicate11so nature ofthe Disclosing
| 1 Publicly registered business corporation
j ! Piivaicly held business corporation
| J Sole proprietorship
f j General partnership
j j Limited partnership
i. I 1 "-lS1
Y>4 Limited liability company
| | Limned liability partnership
j ] Joint venture
[ | Noi-lbr-proiTt corporation
(Is the nol-for-profit corporation also a 5!>Iie>(3>V.J
| ] Yes ! ) No
| | Othei (please specify)
2 for legal entities, thc state (or foreign country) of incorporation or organization, if applicable;
3. For legal entities not organized m the State of Illinois; Has the organization registered to do business in the State of Illinois as a foreign entity?
[^Organized in Illinois
13. 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; (iij for not-for-profit corporations, all members, if any, which are legal entities (Tf 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 orjoint 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
WSUihtSiU H . (.sSIAkhSH. *AtK*t4uC4&L. _
^£-Uf»<5L-. Coougkl 'AtfrKit^et**
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% of ihe Applicant, Examples of such an interest include shares in a corporal ion, partnership interest in a partnership orjoint venture, interest of a member or manager in a
Pa.ue 2 ul 14
limited liability company. or interest o! a beneficial y ol a trust, estate or other similar entity'. 11'none, state "None."
NOTE: bach legal entity listed below may be required lo submit an IDS on its own behalf.
Name Business Address percentage Interest in ihe Applicant
. .z*£yJAgL. -IsL... ^¦¦• (J?:(l... M-.haJ^SiXSu^QAfit „„
.f^e. i-f.^-^-M^^, u_c frtttul. gbcTotj _ ...
X\h±&>.r^cQSJ^... 4i--^.0<^
SECTION III - INCOME OH 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-monih period preceding the date, of this EDS'.' f j Yes 1X1^°
Does thc 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 of the above, please identify below the name(s) of such City elected offieial(s) and describe such income or compensation;
Does any Cily elected official or, to ihe 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?
I | Yes ' f^No
If "yes." please identify below the name(s) of such City elected oflieial(s) and/or sponsors)'domestic parfner(s) and describe the financial interest(.s).
SECT ION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
T he Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-1 56). accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with thc Matter, as well as (he nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Patty is. not required to disclose employees who are. paid solely through the Disclosmg Party's regular payroll. If the Disclosing Party is uncertain whcthei a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure
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Name ( indicate whether Business telained or anticipated Address U) he retained )
Relationship to Disclosing Partv (subconti actor, attorney', .lobhvisi. eic.i
i ces (indicate whether paid in estimated.! NOTE: "hourly rate" or ' ih.d." is.
not an acceptable response.
(Add wheels if necessary)
¦7^4 ("heck here il'the I )iscto.sinti Party has not retained, nor e.xpeels lo reiam. any snch persons or entities.
SECTION V - CERTIFICATIONS
A COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415. substantial owners of business entities rhai conitact with die Cily must remain in compliance w iih 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?
! | Ves IXJ No I j No person directly or indirectly owns 10% or more of the Disclosing Party.
If "Yes." has thc person entered into a court-approved agreement for payment of all support ow ed and is ihe person in compliance wiih thai agreement?
I {Yes I ]No
B. FURTHER CERTIFICATIONS
1, [This paragraph 1 applies only ifthe Mailer is a contract being handled by the City's Department of
Procurement Services.] In the 5-year period pieceding Ihe date of this liDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below j has engaged, in connection with ihe
performance of any public contract, lire 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 ihe vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a contract in progress).
2. The Disclosing Party and its Affiliated Entities are not delinquent in ihe paymcrnof any fine, fee.
lax or oilier source of indebtedness owed (0 the City of Chicago, including, but not limited lo, water
and sew er charges, license fees, parking tickets, properly inxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any lax administered by the Illinois Department of Revenue
Pfli-.i: 4 of 1-1
.'5. The EJisclosing Pany and. ifthe Disclosing Pany is a legal entity, all of those persons or entities identified in Section IlfB ifl ) of tins EDS:
;.nc nol presently debarred, suspended, proposed for debarment, declared ineligible or vohmiarily excluded from any uansaclions by any federal, slate or local unit of government:
have not, dining the 5 years before (lie date of this EDS. been convicted of a ciiminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public ( federal, suite m local) transaction or contract under a public transaction; a violation oi" federal or state antitrust statutes: fraud; embezzlement; theft: forgery; briber;,', falsification or destruction of records: making false siaiciiiems: or receiving stolen properly;
arc nol presently indicted for, or criminally or civilly charged by. a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagraph (bj above:
have not. during the 5 years before the date of ibis EDS. had one or more public transactions (federal, stale or local) terminated for cause or default; and
have not, during the 5 years before (he 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, insiituted by the City or by the federal government, any state, or any other unit of local government.
4 T he Disclosing Party understands and shall comply with (he applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
5. Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in eonneeiion with the Matter, including but not limited to all persons or legal entities disclosed under Section IV. "Disclosure of Subcontractors and Other Reiained Parties");
any "Affiliated Entity" (meaning a person or entiiy that, directly or indirectly; controls the Disclosing Party, is controlled by the Disclosing Parly, or is. with the Disclosing Party, under common control of another person or eniity). 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 entiiy lo do business with federal or slate or local government, including (he City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Conn-actors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Coulractot, is coiiuolled by it, or, with the Contractor, is under common control of another person or entity:
any responsible official (.ifthe Disclosing Party, any Contractor or any Affiliated Eniity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant lo the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entiiy (collectively "Agents").
P;i.:e 5 of N
Ncilhci the.* Disclosing Pany. nor any Contractor, nor any Af filiated Lmily of eilhci the Disclosing Party or any Contractor, nor any Agents have, during ihe 5 yen s before the date of litis EDS. or. with respect to a Contractor, an Affiliated Entity, or an Affiliated Emily of a Contractor during the 5 years before tin: dale o)'such ('onuactor's or Alfiiiated Emily's contract or Ciigageuieui in eonneeiion with the iVl alter:
.bribed, or attempted io bribe, or been convicted or adjudged gnihy of"bribery or attempting to bribe, a public officer or employee of the 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 \\ ith oilier bidders 01 prospective bidders, or been a pany to any such agreemenl. 01 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)(Coiilrac!s Requiring a Base Wage); (a j(5)fDcbarmcnt Regulations); or (a)(())(Minimunj Wage Ordinance).
Neither the Disclosing Parly, nor any Affdiated Eniity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of slate or local government as n result of engaging in or being convicted of (I} bid-rigging in violation of 720 ILCS 5/33E-3: (2) bid-rotating in violation of 720 ILCS 5/3 3 E-4; or (3) any similar offense of any siaic or ofthe United Stales of America thai contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Eniity is listed on a Sanctions List maintained by the United States Department of Commerce, Stale, 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 lo 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 thc City. NOTE: If MCC Chapter 1 -23. Article I applies to the Applicant, thai Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[EOR 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 eoruractors.'siibeouiiaeiors hired or to be hired in connection with the Mallei certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without tin- prior written consent ofthe City, use any such
Vcr.2UI7-l ' lV'.(.'6ofl4
coiuraeiorAsubconrractor lliot tlocs not prtwi^lc: such certifications or ih.-u ibe Applicant h:is reason in believe has not provided oi cannot provide truthful certifications.
1 I. Ifthe Disclosing Party is unable io certify to any ofthe above statements in this Pan B (Further Certifications), the Disclosing Party must explain below.
Jf the letters "NA." the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party ecru lied to (he 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 Pany who were, at any time during the 12-month period preceding the date of (his EDS, an employee, or elected or appointed-official, ofthe City of Chicago (if none, indicate with. "N'A" or '•none").
13. To the best ofthe Disclosing Patty's knowledge alter reasonable inquiry, the following is a complete list of all gifts that lite Disclosmg, Pany has giv en or caused to be given, at any time during the 12-month period preceding (he execution dale of this FDS. to an employee, or elected 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 ofthe City recipient.
C CERTIFICATION OF STATUS AS FINANCIAL INS TIT UTTON
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is is not
a "financial institution" as defined iri MCC Section 2-32-455(b).
Ifthe Disclosing Party IS a financial institution, then thc Disclosing Party pledges;
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge (hat none of our affiliates is. and none of them will become, a predatory lender as de fined in MCC Chapter 2-32. We understand thai becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the Citv,"
I 'aye 7 of 14
Ifthe Disclosing Party is unable tu snake this pledge because it or any of its. affiliates fas defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of VICC Chapter 2-32. explain hcie (anach additional pages if necessary):
Ifthe leiicrs "NA." the word "None." or no response appears on the lines above, it will be conclusively presumed that thc Disclosing Party certified to the. above statements.
i
D. CI'RTTl i( AT'lON REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or ret ins defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-1 10: lb the best ofthe Disclosing Party's knowledge after reasonable inquiry, does any official oi employee of ihe City base a financial interest in his or hei'own name oi in the name of tiny other pe rson or entiiy in the Matter?
I j Yes iVJ No
NOTE: Ifyou checked "Yes" to Item D(E). pioceed io Items D(2) and D(3). If you checked "No" to Item D( 1), skip Items D(2) and 13(3) and proceed lo Part E.
flnless sold pursuant to a process of competitive bidding, or otherwise permuted, no Cily elected official or employee shall have a financial interest in his or her own name or in '.he name of any other person or entity in the purchase of any property that (i) belongs to the Cuy. or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at thc suit of the Cily (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 Pan D
Does thc Matter involve a City Property Sale'7
fJYes 1. JNo
Ifyou checked "Yes" to Item D( 1), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature-of (he financial interest:
Name Business Address Nature of financial Interest
4. The Disclosing Party further certifies (hat no prohibited financial interest in the Matter will be acquired by any Cuy official or employee.
Vcr.2017-1
I: CERTIFICATION KEGARDIN
Please check cither (i) or (2) below. Ifthe Disclosing Pany checks (2). thc Disclosing Party nmsl ii,sclose 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 comveouon with the Matter voidable by the City.
V 1. The Disclosing Pany verities that the Disclosing Party has searched any and all records of the Disclosing Pany and any and all predecessor entities regarding recooE ol"investments or profits fro in slavery or slaveholder insurance policies during the Slavery era (including insurance policies issued io slaveholders thai piovided coverage for damage to or injury or death of their slaves ), and the Disclosing Party has found no such records.
2. The Disclosing Pany \ critics that, as a result of conducting the search in step (!) above, the Disclosing Party has found records id' investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that thc following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: 11 the Matter is federally funded, complete (his Section VL If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI. tax credits allocated by thc City and proceeds of debt obligations ofthe 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 I995. as amended, who have made lobbying contacts on behalf of the. Disclosing Parly with respect to (he Matter: ( Add sheets il necessary):
(Ii no explanation appears or begins on the lines above, or ifthe letters "NA" or ifthe word "None" appear, it will be conclusively presumed thai ihe Disclosing Party means thai NO persons orenlilies registered under the Lobbying Disclosure Act of 1995. as amended, have made lobbying contacts on behalf of the Disclosing Pany with respect to the Matter.)
i
2. The Disclosing Parly has not spent and will not expend any federally appropriated funds lo pay-any person or entiiy listed in paragraph At I) above for his or her lobbying activities or lo pay any person or entity to influence or attempt to influence an officer or employee' of any agency, as de lined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee Vci.2ti! I>:iuo9of)4
of a member of ("nngross. in iinnneuion with the award of any federal I v funded contract, making any federally funded grant or luan. entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally lunded contract, grant, loan, or cooperative agreement.
3 T he Disclosmg Party w ill submit an updated certification a! the end. of each calendar quarter in which there occurs, any event that materially affects the accuracy ofthe statements and information set forth, in paragraphs A( 1 j ami Ai2) above.
'1. Thc Disclosing Party certifies thai either, (i) it is not an organization described in section 50l(ci(4-) ofthe Internal Revenue Code of I9.S0: or (ii) it is an organization described in section 501(c)(4) ofthe Internal. Revenue Code of 19K6 bui has noi engaged and will not engage in ''Lobbying Activities." as thai term is defined in the Lobbying Disclosure Act of \ 995, as amended
5. Ifthe Disclosing Pany is the Applicant, the Disclosing Party must oblain certifications equal in form and substance to paragraphs A(1) through A(4) above from all subcontractors before ii awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for (he duration of ihe Matter and musl make such certifications promptly available lo the City upon request.
H. CERTIFICATION REGARDING LOCAL EMPLOYMENT OPPORTTINU'Y
I'The Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit die following information with their bids or in writing at the outset of negotiations.
Ls (he Disclosing Partv thc Applicant.'
[ JYes " | JNo
If "Yes," answer the three questions below:
I. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations'' (See 41 CER Pari 60-2.)
I JYcs i JNo
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?
f ) Yes .( jNo [] Reports not required
3. Have you parlicipated. in any previous contracts or subcontracts subject to the
equal opporlunilv clause?
I jYcs ! ) No
If you checked "No" to question (1) or (2) above, please provide an explanation.
\'av.ii 10 of 14
SECTION Y U - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
Thc Disclosing Party understands and agrees thai:
Tin- certifications, disclosures, and acknowledgments contained in this FDS will become part of any contract or other agreement between the Applicant and the City in connection with the Manor, whether procurement. City assistance, or other City action, and are material inducements: to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply wjih ail statutes, ordinances, and regulations on which this HDS is based.
The City's Uovcrnmenml 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 WAVSv.citydchieago.orgT-tlnes. and muv also be obtained from the City's Board of Ethics. 740 N. Sedgwick St . Suite 500, Chicago. If 60610, (312) 744-9660. The Disclosing Party must comply fully with this ordinance.
Ifthe Cily determines thai any information provided in litis EDS is false, incomplete or inaccurate, any contract or other agreemeni 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 ibis 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 maybe made publicly-available on the Tniernel, 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 il may have against the City in connection with the public release of information contained in this EDS and also authorizes the City io verify the accuracy of any information submitted in this EDS.
The information provided in ibis EDS must be kept current. In the evcnl of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If (he 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 lo Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kepi current for a longer period, as required by MCC Chapter 1 -23 and Section 2-154-020.
Page II of 14
CERTIFICATION
Under penalty of perjury, die person signing below: ( i) warrants ihat he/she is authorized lo exeeule litis EDS, and Appendices A and B (il applicable), on behalf of the Disclosing I'arty. and (2) warrants that ail certifications and statements contained in this EDS, and Appendices A and B (if applicable), are true, accurate and complete as ofthe date furnished, to the < 'My
jAQ^n^h^^^SAl^pyy^. Uz£-t
( fruit or type exa^t{c-M^ame of Disclosing Party)
Bv;
(SigipltorifO
¦AAlTfAftteL. itMH&K- _ .
(Trim or type name ofperson signing)
OUAtkhN/ygflA^,
(Print or type title ofperson signing)
Signed and sworn to before me on (date) h) f i Z*.
Pane 12 oft 4
Of Y OI CHICAGO KCONU.MIC DISCLOSURE S TALFMLNT AND MTTDW I T
APPFNDLN A
FAMILIAL R F.l .ATTONSII.1PS WITH FLFCTFD CI TV OFFICIALS AND DEPARTMENT HEADS
This Appendix is (n he completed only by (aj the Applicant, and (b) any legal cnlily which has a dime! ownership interest in ihe Applicant exceeding 7.5%. It is not Co be completed by any legal entri) which has only an indirect ownership in I ems I in the Applicant.
Under MCC Section 2-154-015. the Disclosing Party must disclose whether such Disclosing Patty 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 FDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner (hereof 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, bioilier 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 (I) all executive officers ofthe Disclosing Party listed in Section II H.J.a., ifthe Disclosing Party is a corporation; all partners ofthe Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and. limited partners ofthe Disclosing Party, ifthe Disclosing Party is a limited partnership; all managers, managing members and members of ihe Disclosing Party, ifthe Disclosing Party is a limiied liability company; (2) all principal officers ofthe Disclosing Party, and (3) any person having more than a '7.5% ownership interest m ihe Disclosing Party. "Principal officers" means the president, chief operating officer, executive di rector, chief financial officer, treasurer or secretary of a legal entiiy 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?
I I Ves
If yes, please identify below ( f) (he name and title of such person, (2) the name ofthe 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) thc precise nature of such familial relationship.
Piiuc 13 ul 14
CITY OK CHICAGO KCONOMfC DISCLOSURE ST AILMENT AND AFFIDAVIT
APPENDIX U
P.LILDING CODE SCOFFEAW/PROBl .EM I .ANDLORD CERTIFICATION
'EJlis Appendix is lu be completed only by (Vr) the Applicant, and (hi any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). ft is not to be completed by any legal entity which has only an indirect ownership interest in ihe Applicant.
1. Pursuant to MCC Section 2-154-Ull), is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-9.?-4 16?
2. Ifthe Applicant is a legal entity publicly traded on any exchange, is any officer or director of (he Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-4 Hi?
f\.{ I he 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.
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