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OFFICE OF THE MAYOR
CITY OF CHICAGO
RICHARD M. DALEY
MAYOR
January 13, 2011
TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO
Ladies and Gentlemen:
At the request of the Commissioner of Housing and Economic Development. 1 transmit herewith an ordinance authorizing the execution of a loan modification agreement for Wrightwood Senior Apartments.
Your favorable consideration of this ordinance will be appreciated.
Very truly yours,
ORDINANCE
WHEREAS, the City of Chicago (the "City"), a home rule unit of government under Section 6(a), Article VII of the 1970 Constitution of the State of Illinois, has heretofore found and does hereby find that there exists within the City a serious shortage of decent, safe and sanitary rental housing available to persons of low and moderate income; and
WHEREAS, the City has determined that the continuance of a shortage of rental housing affordable to persons of low and moderate income is harmful to the health, prosperity, economic stability and general welfare of the City; and
WHEREAS, the City has certain funds available from a. variety of funding sources ("Multi-Family Program Funds") to make loans and grants for the development of multirfamily residential housing to increase the number of families served with decent, safe, sanitary and affordable housing and to expand the long-term supply of affordable housing, and such Multi-Family Program Funds are administered by the City's Department of Housing and Economic Development ("HED"); and
WHEREAS, pursuant to an ordinance adopted by the City Council of the City of Chicago (the "City Council") on October 3, 2001, and published at pages 67675 through 67685 in the Journal of Proceedings of the City Council (the "Journal") of such date, a certain redevelopment plan and project (the "Redevelopment Plan") for the 79th Street/Southwest Highway Redevelopment Project Area (the "Redevelopment Area") was approved pursuant to the Illinois Tax Increment Allocation Redevelopment Act, as amended (65 ILCS 5/11 74.4 1 et seq.) (the "TIF Act"); and
WHEREAS, pursuant to an ordinance adopted by the City Council on October 3, 2001, ■ and published at pages 67786 through 67794 in the Journal of such date, the Redevelopment Area was designated as a redevelopment project area pursuant to the TIF Act; and
WHEREAS, pursuant to an ordinance (the "TIF Ordinance") adopted by the City Council on October 3, 2001, and published at pages 67795 through 67806 in the Journal of such date, tax increment allocation financing was adopted pursuant to the TIF Act as a means of financing certain redevelopment project costs (as defined in the TIF Act) in the Redevelopment Area incurred pursuant to the Redevelopment Plan; and
WHEREAS, the Project (as hereinafter defined) is located in the Redevelopment Area;
and
WHEREAS, the City Council enacted an ordinance on June 3, 2009, and published at pages 63093 to 63156 in the Journal of such date (the "Original Ordinance") which authorized (i) the provision of Multi-Family Program Funds to 79th Street Limited Partnership, an Illinois limited partnership (the "Borrower"), for the acquisition of land and construction of a building and parking facilities generally located at 2815 West 79th Street and 2751-2757 West 79th Street, in Chicago, Illinois (the "Property") for approximately 9 market-rate residential dwelling units and approximately 76 residential dwelling units contained therein as studio, one-, and two-bedroom units for low- and moderate-income families and of certain common areas (the "Project"), (ii) the
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designation of the Borrower and 79th Street Development LLC, an Illinois limited liability company ("79th Street Development", and together with the Borrower, the "Developer"), as the developer for the Project, and (iii) the negotiation, execution and delivery on behalf of the City of a redevelopment agreement with the Developer for provision of tax increment funds for the Project; and
WHEREAS, pursuant to the Original Ordinance, the City made a loan in the amount of $5,887,767 (the "Loan") to the Borrower, on August 25, 2009, with an interest rate of zero (0%) percent per annum, and secured by, among other things, that certain Junior Mortgage, Assignment of Rents and Security Agreement dated August 25, 2009, made by the Borrower in favor of the City (the "Mortgage") (the Mortgage together with the other documents evidencing and securing the Loan are hereinafter referred to as the "Loan Documents"); and
s
WHEREAS, pursuant to the Original Ordinance, the City and the Developer entered into that certain Wrightwood Senior Apartments Redevelopment Agreement dated as of August 25, 2009 (the "Redevelopment Agreement") for the provision of City Funds (as defined in the Redevelopment Agreement) not to exceed $2,950,000 for the Project; and
WHEREAS, the Project has been completed; and
WHEREAS, the general partners of the Borrower are NHS Wrightwood, Inc., an Illinois corporation (the sole owner of which is NHS Redevelopment Corporation, an Illinois not-for-profit corporation) and 79th Street Development, the sole member of which is 3 Diamond Development LLC, an Illinois limited liability company ("3 Diamond"); and
WHEREAS, at the time of the making of the Loan, the members of 3 Diamond were Ben Klein, Neal Stein and David Porush, as individuals; and
WHEREAS, Neal Stein has relinquished his ownership interest in 3 Diamond (the "Change in Ownership"), and HED wishes to release Neal Stein from his obligations under the Loan Documents and the Redevelopment Agreement; and
WHEREAS, HED has approved a restructuring of the Loan in a manner which (1) will not alter the principal amount of the Loan, (2) will not alter the interest rate on the principal balance of the Loan, (3) will not extend the maturity date of the Loan (items one through three herein referred to as the "Material Terms"), and (4) will consent to the release of Neal Stein from his obligations under the Loan Documents and the Redevelopment Agreement (collectively, the "Restructuring"); now, therefore,
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1. The above recitals are expressly incorporated in and made a part of this ordinance as though fully set forth herein.
SECTION 2. The Change in Ownership is hereby ratified, confirmed and approved.
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SECTION 3. The Restructuring is hereby approved as described above. The Acting Commissioner of HED (the "Commissioner") or a designee of the Commissioner (each, an "Authorized Officer") are each hereby authorized, subject to approval by the Corporation Counsel, to negotiate any and all terms and provisions in connection with the Loan and the Redevelopment Agreement which do not substantially modify the terms of the Restructuring as described herein. Each Authorized Officer is hereby authorized, subject to approval by the Corporation Counsel, to enter into and execute such agreements and instruments, and perform any and all acts as shall be necessary or advisable in connection with any future restructuring of the Loan which does not substantially modify the Material Terms.
SECTION 4. Notwithstanding anything to the contrary contained in the Municipal Code of Chicago (the "Municipal Code") or any other ordinance or mayoral executive order, no parties other than the owner of the Property as of the date following the date oMhe closing of the Restructuring (the "Owner"), any legal entities which are direct owners in excess of 7.5% of the Owner which changed in connection with the Restructuring, and all legal entities who constitute the direct or indirect controlling parties of the Owner (as determined' by the Corporation Counsel), shall be required to provide to the City the document commonly known as the "Economic Disclosure Statement and Affidavit" (or any successor to such document) in connection with the Restructuring.
SECTION 5. To the extent that any ordinance, resolution, rule, order or provision of the Municipal Code, or part thereof, is in conflict with the provisions of this ordinance, the provisions of this ordinance shall control. If any section, paragraph, clause or provision of this ordinance shall be held invalid, the invalidity of such section, paragraph, clause or provision shall not affect any of the other provisions of this ordinance.
SECTION 6. This ordinance shall be effective as of the date of its passage and approval.
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APPROVED
APPROVED lln-.\ (ZjrListhn.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 -- GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 79th Street Limited Partnership
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [X] the Applicant
OR
2. [ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest:__
OR
3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:_
B. Business address of the Disclosing Party: 7444 N. Long Avenue__
Skokie, Illinois 6UU77
C Telephone- 847-6.75-6666x 1028 Fax- 847-329-4900 , Email- dPorush@mtsconsultingcom
D. Name of contact person: David Porush__
26 2330615
E. Federal Employer Identification No. (if you have one): "_
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. ( Include project number and location of property, if applicable):
Removal of Neal Stein from ownership of 79th Street Limited Partnership, the owner owner of Wrightwood Senior Apartments project, 28 W. 79th Street, an 85-unil senior mixed-income housing development which was financed with a HOME loan and a TIF grant
G. Which City agency or department is requesting this EDS?DePartment »f Housing and Economic Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # N/A__and Contract #
N/A
ver. 09-01-10 Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of.the Disclosing Party:
[ ] Person [ ]
[ ] Publicly registered business corporation [ ]
[ ] Privately held business corporation [ ]
[ ] Sole proprietorship [ ]
[ ] General partnership (Is [x] Limited partnership
[ ] Trust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
the not-for-profit corporation also a 501(c)(3))?
[]Yes []No Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable: Illinois
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 [ ] No [x] N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name ■ Title
79th Street Development LLC Managing General Partner
NHS Wrightwood Inc Co-General Partner
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
NHS Wrightwood Inc. 1279 Milwaukee, Chicago 0.0051%
79th Street Development LLC 7444 N. Long Avenue, Skokie 0.0049% RJHOF 8-79th Street LLC 880 Carillon Parkway, St. Petersburg, FL 99.99%
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes [X] No
If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):
N/A
SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the 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.
"Lobbyist1' means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid.basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated to be retained)
Address
Fred Teitelbaum Construction 5526 N. Kedzie
(subcontractor, attorney, lobbyist, etc.)
General Contractor
paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.
$14,167,391 (paid)__
Cubellis (now NORR Illinois) 325 N. LaSalle #700 Architect
$556,000 (paid)
Lighten-Gale Group
203 N. Wabash, #608 Financial Consultant
$225,000 (paid)
Applegate & Thorne-Thomsen 322 S. Green St, #400 Attorney
$219,253 (paid)
(Add sheets if necessary)
[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTTON V CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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.
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Has 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?
[ ] Yes
[ ] No [X] 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
[]N0
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
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2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
c. are not 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 clause B.2.b. of this Section V;
d. have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
3. The certifications in subparts 3, 4 and 5 concern:
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 ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
c. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the. following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
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If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that the Disclosing Party (check one) [ ] is [X] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D. ,
1. Tn accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ] Yes [x| No
NOTE: If you checked "Yes" to Item D.I., proceed to Items D.2. and D.3. If you checked "No" to Item D. 1., proceed to Part E.
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2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit 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 PartD.
Does the Matter involve a City Property Sale?
[]Yes []No
3. If you checked "Yes" to Item D.I., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
_2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
i
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SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
None
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the 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 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
3. 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 A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
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B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[X] Yes [ ] No
If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[x]Yes []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 all reports due under the applicable filing requirements?
(X] Yes [ ] No
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [X] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
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Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
F. l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party 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 F. 1. and F2. above and will not; without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
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NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Parry, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
79th Street Limited Partnership
(Print or type name of Disclosing Party) By: 79lh Street Development LLC, Its general partner
David Porush (Print or type name of person signing)
Manager
(Print or type title of person signing)
Signed and sworn to before me on (date) D CCOr^^z 12-P CD at Coo (C_County, 1111 Ko i S (state).
ju^qX1V\ 0^JL'LlsU^<U_ ^ Notary Public,
Commission expires:_
m£FFIC,ALSEAL MARGARET M TINUCCI
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following-, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section Tl.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [X] No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the 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 13.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/if applicable: 79th Street Development LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. [x] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: 79th Street Limited Partnership_
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:_'
B. Business address of the Disclosing Party: 7444 N. Long Avenue_
Skokie, Illinois 60077 ~~
D. Name of contact person: David Porush__:
E. Federal Employer Identification No. (if you have one): 26-1502051_
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Removal of Neal Stein from ownership of 79th Street Limited Partnership, the owner owner of Wrightwood Senior Apartments project, 28 W. 79th Street, an 85-unit senior mixed-income housing development which was financed with a HOME loan and a TIF grant
G. Which City agency or department is requesting this EDS? Department of Housing and Economic Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification #___and Contract # N/A___
ver. 09-01-10 Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of the Disclosing Party:
Person [X] Limited liability company
Publicly registered business corporation [ ] Limited liability partnership
Privately held business corporation [ ] Joint venture
Sole proprietorship [] Not-for-profit corporation
General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No
Trust [ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable: Illinois
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 [ ] No [X] N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
3 Diamond Development, LLC Sole member
David Porush Manager
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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, interest of a member or manager in a limited liability company,, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
3 Diamond Development, LLC 7444 N. Long Avenue, Skokie 100%
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes [X] No
If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):
N/A
SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
N/A
(Add sheets if necessary)
[X] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [ ] No [X] 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 []No
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section ll.B.l. of this EDS:
a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal,- state or local unit of government;
b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
c. are not 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 clause B.2.b. of this Section V;
d. have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
3. The certifications in subparts 3, 4 and 5 concern:
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 ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; . ,
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
c. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code. r
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
J
Page 6 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that the Disclosing Party (check one) [ ] is [X] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[]Yes [X]No
NOTE: If you checked "Yes" to Item D.I., proceed to Items D^2. and D.3. If you checked "No" to Item D. 1., proceed to Part E.
Page 7 of 13
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property'that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit 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. If you checked "Yes" to Item D.I., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
_2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
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SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
None
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the 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 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
3. 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 A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501 (c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
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B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[]Yes [x]No If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[]Yes []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 all reports due under the applicable filing requirements?
[ ] Yes []No
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" to question I. or 2. above, please provide an explanation:
SECTION VII-- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Page 10 of 13
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
F. l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
Page 11 of 13
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
' 79th Street Development LLC
(Print or type name of Disclosing Party)
By:
David Pomsh
(Print or type name of person signing)
Manager
(Print or type title of person signing)
Signed and sworn to before mc on (date) Dfc CrrSo ^ \ Le. Hz;) c O at L&Ot£- County, 1 lh noiS (state).
Commission expires:
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section TLB. 1. a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Parmer thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [x] No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of the'Disclosing Party submitting this EDS. Include d/b/a/if applicable: 3 Diamond Development, LLC V
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. [x] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: 79th Street Limited Partnership__
OR
3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:_.__
B. Business address of the Disclosing Party: 7444 N.Long Avenue____
Skokie, Illinois 6UU77
C Telephone- 847-675 6666x 1028 Fax. 847.329.4900 Email- dPorLlsh@mtsconsulting-com
D. Name of contact person: David Pomsh_____
E. Federal Employer Identification No. (if you have one): 26-2574835__
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Removal of Neal Stein from ownership of 79th Street Limited Partnership, the owner owner of Wrightwood Senior Apartments project, 28 W. 79th Street, an 85-unit senior mixed-income housing development which was financed with a HOME loan and a TIF grant
G. Which City agency or department is requesting this EDS?DePartment of Housing and Economic Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # N/A___ and Contract # _
Ver. 09-01-10
Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
Person [x] Limited liability company
Publicly registered business corporation [] Limited liability partnership
Privately held business corporation [ ] Joint venture
Sole proprietorship [ ] Not-for-profit corporation
General partnership (Is the not-for-profit corporation also a 501(c)(3))?
Limited partnership [ ] Yes [ ] No
Trust [ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable: Illinois
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 [ ] No . [x] N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Ben Klein Principal
David Porush Principal/manager
2. Please provide the following information concerning each person or entity having a direct or ■ indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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v interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
Ben Klein 7444 N. Long Avenue, Skokie 50%
David Porush 7444 N. Long Avenue, Skokie 50%
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[]Yes [X] No
If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):
N/A
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to'Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
N/A
(Add sheets if necessary)
[X] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [XJ No [ ] 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 [ ] No
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party . certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
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2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
c. are not 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 clause B.2.b. of this Section V;
d. have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
3. The certifications in subparts 3, 4 and 5. concern:
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 ineligibility of a business entity to do business with federal or state or local government, including , the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible.official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
, f
c. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
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If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that the Disclosing Party (check one) [ ] is [X] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A
If the letters "N A," the word "None," or no response appears on the lines above, it will be 4 conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ] Yes [x] No
NOTE: If you checked "Yes" to Item D.I., proceed to Items D.2. and D.3. If you checked "No" to Item D.I., proceed to Part E.
Page 7 of 13
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit 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. If you checked "Yes" to Item D.I., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either I. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City. ^
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
_2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
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SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
None
(If no explanation appears or begins on the lines above, or if the letters "MA" or if the 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 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
3. 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 A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
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B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[ ] Yes [X] No
If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] 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 all reports due under the applicable filing requirements?
[ ] Yes [ ] No
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
SECTION VII-- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that: ;
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Page 10 of 13
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
F. l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the Cjty. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
Page 11 of 13
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
3 Diamond Development, LLC
(Print or type name of Disclosing Party)
(STgrTnere)
David Porush (Print or type name of person signing)
Principal/Manager (Print or type title of person signing)
Signed and sworn to before me on (date) £W<?-/yit>?/ I b?, "jJD [ O
By:
at Coo^~
County,
w
<s (state).
Commission expires:
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [X] No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
NHS Redevelopment Corporation
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. [/\ a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: 79th Street Limited Partnership_
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:_
B. Business address of the Disclosing Party: 1279 N. Milwaukee Ave._
Chicago, IL 60622
Deborah L. Dixon D. Name of contact person:___
E. Federal Employer Identification No. (if you have one);
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable): Withdrawal of Neal Stein from the 79th Street Limited Partnership ownership in the Wrightwood Senior Apartments project, 2815 W. 79th Street, an 85-unit senior mixed-income housing development which was financed with a HOME loan and a TIF grant.
Department of Housing and Economic Development
G. Which City agency or department is requesting this EDS?_
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification #_and Contract #_
Ver. 09-01-10
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SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of the Disclosing Party:
Person [ ]
Publicly registered business corporation [ ]
Privately held business corporation [ ]
Sole proprietorship {/]
General partnership (Is Limited partnership
Trust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
the not-for-profit corporation also a 501(c)(3))?
[/Yes []No Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable: Illinois
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 []No [/N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
]. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title See attached list of Board of Directors and Officers
NHS Redevelopment Corporation disclosing
Neighborhood Housing Services of Chicago, Inc. Sole Member
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
N/A
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[]Yes f/fNo
If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
f/ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [ ] No t/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 [ ] No
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
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2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
c. are not 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 clause B.2.b. of this Section V;
d. have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
3. The certifications in subparts 3, 4 and 5 concern:
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 ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
c. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, 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 (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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
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If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that the Disclosing Party (check one) [ ] is [/ is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-45 5(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary): N/A
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[]Yes [/No
NOTE: If you checked "Yes" to Item D.I., proceed to Items D.2. and D.3. If you checked "No" to Item D. 1., proceed to Part E.
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2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit 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. If you checked "Yes" to Item D.I., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
N/A
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
J 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
_2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
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SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary): N/A
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the 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 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
3. 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 A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
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B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[]Yes [/No If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[]Yes []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 all reports due under the applicable filing requirements?
[]Yes []No
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
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Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
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NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Parry, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
NHS Redevelopment Corporation
(Print or type name of Disclosing Party)
James K. Wheaton
(Print or type name of person signing)
Authorized Signatory
(Print or type title of person signing)
Signed and sworn to before me on (date)
Notary Pufilio. <^se«.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section HB.l .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes ]/[ No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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NHS Redevelopment Corporation
DIRECTORS 2010-2011
The NHS Redevelopment Corporation by-laws establish a variable range of Directors of the Corporation at a minimum of eleven (11) and a maximum of sixteen (16).
BETTYE BAKER-HOUSTON, Secretary Community Resident
BEN GILLSPIE
Chase Bank
VACANT, Vice President
KRISTINE JURMU, President Bank of America
CHRISTINE KOLB
Urban Land Institute
ROBERT MCGHEE US Bank
FLOYD MINOR
Community Resident
STEVE QUASNY
Harris Bank
JOHN RUSH
Cara Program - CleanSlate
DANIEL SIADAK
Bank of America
ADRIENNE WHITNEY
Community Resident
JUDYZABA
Community Resident
CITY OF CHICAGO ECO NQlVl IC D IS'CL6 S URE, SjT'ATEMENT AND AFFIDAVIT
SECTION 1 - GENERAL INFORMATION
A Legal name of the Disclpsing,Party submittingthis EDS. include d/b^a/ if applicable: NHS WrightAvpbd Inc.
Check ONE of ihe following three boxes:
Indicate! whether-the Disclosing Party-submitting.this-:B0$ is: T. [ ] the Applicant OR
<2r '{/{ a/leg'al eritityhblding a director indirect interest iri the Applicant:. 'S&T.ethe legal narne>of the: App|ic:^ht inL which.li'e Disch^smg.Party holds an interest; 7^rVStreet LimlWd Partnership
'OR ' ' ' '* ' ' ' " '.....
31 [] a> legal entity Syith a right of control ("see Section 'UJ3-1.)' State the legaihamf of the entity jh which tliie Disclosing Partyliblds a right of cpntrbl:_- _
B; Business: address of th^ Displosin^Party: 1%;N.^!waukee Aye, , _
'C|ii^^,-;lI.eo'ei22'
G. Telephone: .y 'r' '."-.' '_Fax: ' _EmanV ■ ■ ■ ■
. .... Deborah i L. Dixon;
iD. Name .ofcbhtac^peTsqh: ... _
E: Federal Employer.Identification No. (if you have one):_ . . ._. ...
F: Brief' description of contract, transaction' or other, undertaking ,(referfed; to'below ias the "Matter'I), to .which ttijs:Ep.S)ipertains. (Include project numberand location of property,, if;applicable); Withdrawal of Neal Stelri.frbm the 79th, Street' Uimifed' Partnership .ownershiip'ln the Wrightwood Senior Apartrhenls project; 2815 W. 79th Street, art ^u.rilt senior mlxed^ncgrna hoUBirig development wHicti was financed wilh a HOME loan and aTlpgrant.
,., ., ...... . . . O'epaftrhent pfiHpiising and EcphomicDeV^bprnshl.
Wnich pity ageney or department is requesting this EDS'? : _ '' .
If.'the/M^ the'jGjity's. D^arfffie'Ht p^'Px&^rehierit 'SeWfc/es; .please,
complete tie following:1
j ' r * 41 -
ft- ... ^ ■
'Spe_cificatiqri'.>■#._^_and'Cpntracl _
Ver-69-61-iq
Page: i df' i3',
SECTION It --DISCLOSURE OF OWNERSHIP INTERESTS'
A. NAT'tlR'E OF THE; DISCLOSING PARTY
J. Lridicatc the: nature,of'the DisclosirigiParty-
[ ], Person [] Limited liability.company
X ], Publicly; registered'bus^ i[ ] Limited1liability;.partnership
\/\. Privately held business cprpbratipn '[.] J pint venture
:(']; Sole prpprietdrship. [ ] NQt^fpi^prp^tbo^ttrtrtph
[]' G en era 1 lpa rtri ersh ip (Is the' hpt-for-profit corporation also a. 501 (c)(3))?. [ J Limited'part^ I]Yes [jNo
[ t Trust [.] Otter (please «^ecify)-
2: For legal entities, the state-{br foreign*country) P$ihcpr^pratiori:-6t prganizatiori, if appiicabje:
Illinois
3.; For legarentitie.s npiiprganized imthe State of Illinois: Has ibe; organization registered1 to dp business in the State of jllinois.as alfprfeignfentity?-
[ ] Yes ['] No \/[ N/A
6, IF THE DISCLOSING PARTY IS A LJjGAL ENTITY:
1. List below the full narrie's and titles,of all executive' officers and ;all<dir^ NOTE: iFor not-for-profit Corporation's, also list bciow.all members, if any,- .which ate legal entities. If there are no such members, write !'no members.,1'' For tmsts;.es^ the-legal. IiUeholder(s).
'\X the "entity -is a; general^artriership/'limited parVnbr^hipVlimi^d liability ,c'pmpany, limited liability partnership or jbirit vehtujre, listbclp.w trie name and title; of"each general;partner; rnanagin manager pr'ariy Other person .or'entity thattcphfrpls the day-^ Party. NOTE: OEachjlegf I entity iisted below must submit an EDS'.on .its'own".beba.tf.
Name 'Title iDeborah'L.bixon PrSwident/Treasurer
James ;K: Wheatori Vice RresidenryAssista'iit Secretary
Robin,Coffey; Secretary
2. Please provide' fie fpjlpiyirig information. cQhcerniiig each person oV-eh'ti.ty having a direct or indirect beneficial interest (including ownership) in/excess. of7.-5% of the Disclosing Party Examples-Pf'such an interest include shares iri acorppratipn, partner.ship mterest in'a partnership P.r jpiiit Venture,,
Pag'eiZ'pf' 13'
interest of a. member or manager in .a iimited liability company,; or interest of a beneficiary of a trusty esta'fcor other si rnjlar entity. If none; state "None." NOTE: 'Pursuant to Section 2-15.4-1030 ofthe. Municipal Code of Ghicag0!("Municipai Code"),- the Giiy may require any. s'iich.'additiohal-jirforroatiQh from any appiicant which is reasonably intended to acl\ieve;fuji disclosure,,
Name Business Address Percentage Interest in the
Disclosing Party
NHSRede.^ '1279 N, MjlwUate^ 100%.
SECTION lit - BUSINESS R E L A TIONSHIPS: WITH CITY ELECTED OFFICIALS
Has'the; Disclosing Party hada. '"business relationship^'1 -as defined iri1 .Chapter 2-V56 of the Municipal 'Code; with any. G 12 months,before the; date ithis.EDiS is signed?
,[]Yes 'l/iNo'
if yes- pleasej.dchtify belp.w the.name(sj of sucjiiGiiy-elecleJ^q^ci^lCs); and' describe fudh >relati6riship(s;):i
SECTION IV V DISCL OS0.RE 6 F- S U B C O Nf CT O RS AND OTHER RETAINED PARTIES
The 'Disclosing Party inust 'j^sc^^.sc^thc^'name. and business address pT ear^^ubcontf a cipr, attorney;. ldb^yis^acD9untant,;ec>ns'nlknt and;any other person or'entity whom tlie.DIsclbsing Party has retained pr'expects to retain in connection with the Matter, as well, as the nature of the.relationship,, and the-total' :amo'iint of the fees paid or estimated tp'be paid'. The Disc losing Party is not required ipdiscipsp Employees Who are p^id solely through, the D-isclosmg, "P-ariys.regular payroll;
"Lobbyist" means any person or entity who undertakes to influence any legislative or'admihistrative action on behalf of any person of entity other than:(i) a not-for-profit entity, p an unpaid basis, ori.(2). himself. "Lobbyist" also means any person or entity any part of whoseduties -a's; Sui employee, of ariotJief includes undertaking to influence any legisiatiye or/admihis.ri.atiyc action,
If the-pisclpsing Party is uncertain whether a disclosure is requiredunder thjs Section,, the 'Disclosing Party must-either,<ask the City "whether, disclosure is .required'or- make ;the disclosure:
Page 3 of J 3
Carrie(indicate whether Business Relationship td.Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney;, paid or'estimated.) NOTE:
to be retained) lobbyist;etc.) "hourly^ rate" or''t.b.d.,? is
not an acceptable response.
(Add sheets if necessary)
^ Check here if the Disclosing Party has not retained, .nor expects to retain, any such persons or entities. SECTION V - CERTIFIGATIONS
A, COUR'f ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal CodeSection:2-92-415,j substantial owners of business entities that contract with, the City niust Temain in compliance with their child support obligations through but the contract's term.
Mas any person who directly or indif ecUy pwiis 10% or more of the Disclosing Party been declared .in arje'aragS'6n .any ;phiid support obligations by any Illinois court of competent jurisdiction?
[, ] Yes [ ] No t/f 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 pa.yment of all support owed and is;the person in com'pliacice with that agreernent?
[ ] Yes I J No
B. FURTHER CERTIFICATIONS
I. Pursuant to Municipal Code Chapter,l-23, Article I ("Article l")(which the Applicant should consult for defined terms (e.g;> "doing business") and legal require'rrieius),. if the Disclosing Party submitting this EDS is the ■Applicant and is doing business withthe City, then the Disclosing Party certifies as;fp]lpws: (i).neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has everhcchicptivicted of, or'placed Under supervision for, any criminal offense;ihyolvihg actual, attempted, Prconspiracy to cb.rnmit bribery; tK^ perjury, dishonesty or deceit against ah pfficerpr employee of thc City oraiiy'sister agency; and (ii).thc Applicant understands and acknowledges that compliance with Article I is a continuing requirement1 fpr doing business with die City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some, five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
2. The'^ispld^ihg/F^arlyyand, if the Disclosing Party-is a legal entity* all of those persons^ or entities identified in Section 1I.B.1. 6'f this EE'S:
a. are not presently debarred, suspended; proposed fof deparrhent, declared ineligible of vpluhtarjly excluded from any1 transactions by any federal;- state or Ipcal.unit Pf gpycrnrnerit;.
b; have not; within a fiveryear period- preceding Uie-date of this EDS, been convicted of a; criminal offense, "adjudged guilty, prha'dja civil judgment rendered against themi[ih'C©,rmectio^-wjth: obtaining, .attempting, to obtain, or ,performing, a public (federal, state or loca l) transactibn 'or contract under a public transactipn; a violation of federalpr state antitrust statutesi.fraud:; fepibemlernent; tfieft; forgery; bribery; falsificatiqh or destruction of records;-making, false stalernents; pr receiving stolen property;
c\ are not presently iridipted ipr,, or crirnirially bjr;C entity (federal
state of local) with committing any of the offenses: set fort-hiin. clause B'.21b':'6f this Section' V;,
d-i have not, within a fi ve-year period preceding the;da te; Of'this fep,$';,b.a;^.9nie''pf: riiqre public transactions' (federal, state or- 'ipcai) tenninated'fpr cause-or default; and
e>. have not, within a fiye-yfe.afpenPd' ;p^bje1ding: the^date of this EFjS- b'ee.n convicted, adjudged guilty, or found liable iti a civil proceeding, pV irj any criminal'pr "civil action concerning environmentalyidiatiPns, instituted by the City or by the fj^erai'gpv'ernmpnt. any state, or any other unit bfloVal- government.
3;. Trie certifjcations in subparts 3!-, A arid ,5; concern:
? the'Disclosing Party ;
iny "Contractor" (meariihgany cpntractpr or^ubebntractpr-used by' the Disclosing' Party in connection with the Matter; including'butinpt limited to all persons 6f iegal enti'iJeS'disc 'Section lVi "Disclosure of SubcqnixactPrs'arid Cuher Retained Parties");
* any "Affiliated Entity" (meaning' a person or Entity that, directly or indirectly: controlS'the '.Disclosing1 Party; is contrpliediby the Disclosing. !Part$ .or is', with me Disclosing Party, under ■common control of another person or" entity., fodjeia of cpi^t.rpVinclu.de^-Vi^out limitation:' interlocking management p;r ownershjp: identjty'oT'intere^ts arnphg family members; shared facilities aha* equiprpent;^.pmropft- iise'- of employees; p'r organization of a business! entity following the ineligibility ,pf a'tusiness entity to dp bu.sihess/.w.ilb. fedenit or state or Ipcai gpyenyji.eiit^ incTudihg the dity, using substaiitiaily the.s^rne .management, pwher^hipi,or principals as the ineligible entity);, with respect td Contractors.; the-.tcnri. Affiliated Entity rneaiis-a.person;or entity that directly or-indirectly [controls the Contractor,-is controlled by,it,.'or. with the Contractor, is under'cPmrriPn control of another person, or entity;.
* any responsible official'of the Disclosing Party, any Cpntractpr or any AffiliiterJ Entity or any Other official ; agent or employee of the Disclpsing Party; any. Contractor-pr any AMliaietfEnttfy, racing pursuant to die direction or authorization of a responsible official of the Disclosing Partyi any Cpntractpr or any A ffiliated Entity (collectively "Agents").
Page 5 pf-13
Neither the .Disclosing Party, nor any Contractor, nor any. Affiliated Entity of either .the Disclosing Party or any Contractor nor any Agents haye,-during the five' years before the date1 this EDS' is signed, or, with respect to a Contractor,, an Affiliated Entity',ipf an Affiijaicd Entity of a (jtontiactprduring-dip--five' years before the date of'such CPhtractor's or Affiliated .Enth^s^cPntr'acitpfr epgagerhpni iri>cphnect.ipri with the Matter:
a: -bribed -Pr ^attempted1 tp -"bribe; .pr beenvconv'tcted pr adjudged guilty of bribery'or attempting "to briber a public officer or employee of the'City; the (Statp'of^Illinois; or any agency of the federal: gover-nment-Pr of any 'state or IPcal government in the Uhi led S tales of America, in .that officer's, or emplPyee's,official Capacity;
b. agreed 'orcojjuded! wiUr b'ther'bidders of prospectivcbjddcrs, or be.cri a partyto'any;§uplj' agfeerheh^-pr'b.ecn'Pon-yiCted pr^djudged guilty of agreement or collusion among biddefs:or prospective bidders, in restraint of- freedprn'ofeprppetitiqiv pY^a'gfe.einentto bid a fteiiprjpe/ipr.' pthenyise; or
c. madeau adrPi.ssjpnof such conduct described in a. or b, abpv.e.that is a matter o f record,, but have not been prosecuted for s,uch;c6.riduct;;or
d. violated flip-'prpvi.sipn!i,0'f MunicipalCjjdjB.Section 2-92-610; (Living Wage Ordinance),
4. "Neither the Disclpsing Parly, Affiliated .Entity .pr. Gbntrac'tPr, p.r: any pf their emplpyees, oiffi'c'iai'sj agents or partners, is barfed frcrti contracting wUhany-unit of state or local government as a. result pf -engaging'in or being convicted of (1). bidvrigging In. violation of 720 ILCS 5./33EO; :(2)rb.idVrptafing in,-Violation of 720 ILCS.5/33Er4; of (3) any similar offense of any -state or of tlie United States of Aiubficathat containsjthc same ciefhents as the offense of bid-riggihg Pr'bidfrptatiii'g:
5: .Npifhcf the Disclosing- Party hpr.aiiy Affiliated Entity is listed1 On any-of the following lists'' maintainediby the Office of Foreign Assets Control of the'-U.'S'. Department -of- the* Treasury -Pi-'tije, Bureau of Industry and 'Security of the y .S.;, Department of Commerce or theirsupcesspf sivthe Sp;ec,ially - Designate^Nationals List', the D efied Persons List; me;Unycrifib;d:List, the, Entity List and th;6. bebarfpdjList.
6. Thep.isclpsing Party-understands and shall comply w-iu*the^ap^iieable-re^uir^'eunts of Chapters: 2-55 (LegislativP'Mspectpr General), 2r56 (Inspector General) and 2-15pXGpyernmenial Ethics) pf the Municipal Code.
"7,. Jf the Disc losing Party is'unable tocertify tp any Pf the. above statements in this1 Part- B}(Further Certifications), foe Dis'closmgpiarty must explain bPlp'vf:
Page 6 of 13
if the letters "N A j5.1 the word ''None,'' pr hp response appears bri ^e ilines. above, it -will ;.be. Conclusively' presumed that the' Disclosing Party certified! IP the above - statements'
C:' CER ft FIG AT ION OF STATUS AS FINANCiAL fN.STlTjJTiQrV
I: The Disclpsing Party certifies that the Disclosing pahy (check/pne)
[ ] is '^f as not
a "financial institution" as defined in Section 2-32i45'5'(b')'of the Mt&ipipal Code.
2 : If the Disclpsing'Party IS - a financial^institution;, then the Disclosmg P^r^.pl'ed^.?.;'-
■'We are'not and wili'.not become a pred'aton' jender as defined "n Chapter 2-32 of the: Municipal Code. We further pledge ,that npne pf our- affiliates is; and nphcpf them will become; a prpdatpry lender as defined in Chapter 2-32 of the Municipal Code. W(e .understand that becoming fpreda'tpry lender or becoming an affiliate of apfpdatbry'lcridermay result in the loss of the privilege of doing busirie.ss vvith the'City."
If thpspisclosing Party is unable to make this pledge because it pr ;ariy pf ite-a-Mtiates" |asi dcfiriea in "Section 2 r32-455(b) of the Municipal Code) is '^'pVedatpry'.iPnde^ within the meaning of'Chapter
2-32 of the Municipal Code, explain 'here(attach,addi tional pages; jf hecessaty);
Kl/A, ' ■ . . _ .' ^....._'...._................
if the letters "N A die Word. ?Ndne." or hbresponse; appears ;ori the lines,above;; it wili be-conclusivelypresumed th'at the bipcjpsiiig' Party certified to'-'tbejabpve.'staterPents\
D". CERTIFiCATiON
Any words or terms, tiiat are defined hi Chapter.-2;-'l So*' -of the Municipal] Code have the>sarne meanings when used'in this Part D.
1. ln»accprd.ance with Section'2-156/110'of the ,Municipal prprnRlPyee p;ftthe £ity have a financial' interest in his or her own natrie or in the name'6f Any other person, or eritity in the Matter?
[J Yes- No',
NOTE:: If you checked "Yes" to Item D.^.,pi;p,ceed to Items. $.2-and D.3-, If you, pjiepked "-N6" to 'itpm D:i.; proceed "to Part E;
Page 7 of 13
2. Unless-sold pursuant to,a process of competitive bidding; or otherwise permitted, no City ejected official or employee shall have a financial interest in his or her owri namepr in the name of any.pther person of entity in the purchase of any property that (i) belongs to the City,, or (iij is sold for taxes pr assessments, or (iii)' is sold by virtue of legal'process at the'suit of the City'Ccplleciiyely, "City Property Sale"). Compensation for property taken pursuant tc( the; City's; eminent dornainpower does not constitute a financial interest within the meaning of this-Part D;
'Does the'Matter,involve a City Property Sale?
3., -jf y'oii:Checked'"VPs'.' tpjtem D\lprpyi'dc tht.narnes arid business;,ad'o^csscs",pf.thc City 6fficiais/6f- emplpyees.hayi'hg such interest aKd.ideh'tifj/'tlie hature'bf such interest:
'$arhe Bus mess .Address ' $ aiurc' .of'Interest
4'. The P'iscldsing Party further certifies that np,prohibited financial'interest in the Matter will be acquired by'any City official or employee.,
!E:,p'£;i^TiF'fbATi0N' REGARDING SLAVERY EiWiB^S^ESS
Pleaserchcclt; either k Or 2i below-. If.meibiscl^sing'iP'arty' cheplcs:2.,/)$e< disclpsing Party mus t "disclose below or in an; attachment to this EDS all information required by' paragraph 2. Failure^p ■comply wi.m'these. disclpsufe re mafceany contript entered into With the City in.
connection with the Mattervoidable by the City';
.'tf li: 'The Disclosing Party Verifies that the Disclpsing P^
the E)iscjosilig Party and any.and all pfedecessof entities regarding records Pf inVPSWents or.profits ffpm.:sla"yefy of slayehpider insurance policies during the slavery, era (including insurance policies issued to,slaveholders that provided coverage for damage' to or. injury or death.pf Jtheir slaves), arid the bisclosing' Party has found no-such records
______2: The Disclosing Party verifies.that, as ajresu.lt ofconducting the search ifhstep 1 abby.e. the
'bisclosing Party has fpund records,of investments p'r- profits .from -slavery slaveholder insurance policies. The Disclosing Party verifies that the following constitutes f^Il disclosure p,f all, such records, anchiding;thc names Pfahy.and^alfslayesiior, slaveholders d rbosb', records:
Page 8 of .13
.SECTION V I. CERT IFICAT ION S f6r 1 FED E RA L L Y FU'JS DE D 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'Sectiorji VI, tax-credits allocated "by the City and proceeds-pf de.bt-pbligations Of the' Oily, aremot federal ftinding.
A. 0 E R T {F}CA'TION REGARDING LOBBYING
1. List below the names of all persons pr'entities registered under the federal'Lobbying, Disclosure Act of 1995 who have- made lobbying contacts OnTi>ehalf p£the Disclosing Party--with respect to1 the Matter: (Add'sheets-if necessary);
(If hp explanation appears Pf begins pri the. lines ab.oye, or if the .letters "N A-'pf if the w'prd "Nptic"1 ap'pe'ar, it will be conclusively^presumed/that.the Disclosing Party^ means thaf NO perspns or entities registered under the Lobbying Disclosure Act Of i 995 have -ttiadP .lobbying- contacts-on behalf of the Disclosing Party with respect to the Matter.)
2: Th'p, Pisclpsjhg"Esurty has not sperit and1 will not'expend any. federally, apprppriate pay .airy p'ersp|n or entity listed' in Paragrapj) A :) - above for his or her lPbbying;activities pr to pay any pVfSdn of eptity to influence orattempt to influence an officer, premplpyee of any agency, as defined by applicable federal law,, a member of Congressman, Officer or employee Pf Congress,, or1 an employee pf a mernber of Congress-, in connection \yith the award of any federally funded contract,, making any federally funded grant pr loan, ente'ring,ihtp :any cooperative agreement or'tp'.ex-tendjjcbhtinuej renew; amefid, pf modify any federally fiinded contract; grant; loafij or epoperative agreemerit.
3. The Disclosing Party will submit an updated certificotion at the end of each Pal pn da r quarter in ■ which there occurs any event that materially affects the accuracy of thei statements and information .set, forth iri paragraphs A.l. and A.2/abpve
4'. The jS.isclpsing,Party certifies, thai either; (j) it is npt an prganizatibn described jq section .5bl-'(c.)(H}p;C;tb>Internal Revenue:Code of 1/98-oriCiii it is:.an Pli|i4m^^dn-despFi.l^d 'n section 501(c)(4)of the Internal Revenue >Gpde df 198.6: but hPs\npt ehgage Apt iyi ties".
5. If the Disclosing Jfiarty is the-Applicant, ,£he disclosing Partjfr must obtain certifications equal in fprftt and Substance to paragraphs, A.l.'. through A.4. above from all Subcontractors before it awards any .subcontract and the Disclosing Party--mu$i'inaiptaix) -all-Such -.suticontraptpT^' certifications for the duratipri' of the Matter and must make such pcrtifications promptly available 'tp.the City upon request.
Page 9 6f 13
r - '
B, 'CERTIFICATION REGARDING EQUAL EMPLO YM'ENT'0PP0RTUNITY
If the Matter is federally funded, federal regnjlatibns require the: Applicant and all.propqsed subcontractors to .submit the following information with their bids'pr in-writing at the-butset of. negbfiatjorisi
js the Disclosing, Party:the Applicant?'
ij'Ycs t/I ISO
J-f ^-Yes," answer the-three question's belpw:
1: Have you 'devrilpped and. do ypu havei-pn,- file affiimaUve'act to applicable
fedjejraT reg^lati'p^s?>i:$ee;;4-l .CFR/Pajrf 6Q>'2.)< [iO "Yes []'No'
2: Have ypuifiled with the Joint RepbrtiHg Gpm.mi.ttepj the -Pjrectbr' of the'Office'bf Federal Contract Compliance P/ograms; of the Equal Employment .Opportunity.GPrntoissiPh aII reports ,due: under the applicable filing fequifemehts? '
N Yes ' fl No
'3/ Hjave ypu participate'diiri any previous contracts,pr.subcphtr'acts Subject tp the 'equal opportunity clause?
'[ J'Yes []Np-
If you cheeked k'Np" to question 1. Pr 2: aljoy>,-pj$as£ prpyjfl^'afe explanation;
SECTION VII ~ AC'KJN0WLED.GMENTS, CONTRACT INCORPORATION.; COMPLIANCE, PENALTlESi DISCLOSURE.
The Disc losing Party undersiatids and; agf eps\ that:.
A. The certifications, disclosures'; and apkjnpwledgmerjts contained ih ihjs EDS will becprneipart. of any-contract or other agreement between the. Applicant arid the City in cp.nncctlpn with the Matter, whether prppuirernentj City assistanc.e. or pther City action; and are material inducements'to the City's execution of ahy Ppritract or tajking other action with, respect.to tie Matter. The Disclosing Party understands that it must cpmply With all -statute's', ordinances, and regulatiPris on which this EDS; is ,based.
B:, ftip'.CKy?s-.Gove.ilimientai Ethics,and!CaPipaign pinanpihg Ordinances,Cha'piers :2t 156.and 2T1'64 bf 'the'Muni'pdpal'Code, jmpPs'e.ej6rtifm duties, and obligations on-persons,pr-entities seeking City cpn'tfactsi wpfkj busmpss, or transactiphs.- The,ful|rext pf these ordinances, a.nd.a training program is: ayajlabie pn line at www.cityofchicago-.ore/Ethics; and may'also be-obtained frpm1 the City's BoardI-of Ethics, 740 N;
Page iO of 13
Sedgwick St., Sy'itc 5Q0i ehicago; IL 606,10;■■ (312); 744r966p. The Disclosing Par^'Bi'usHprapiy'tb.liy with the applicable ordinances;
C-. If the City determines that any intorrnatipn provided! in this EDSJsrfalsc,. incomplete-or inaccurate; any.cbfitract or other agreement in connection with which it'is stibmilte'd may be rescinded or be voider voidablej arid the City may pursue any remedies, under the contract oragreement^if.'npt.rescindPd of Void), at law} Pr in equity; including terminating the bisclosing Party's participation 'inVtfie-Matter'arid^or declining to allow;.(he Disclpsing Party tp'participatc in.ipther transactions with the City. Remedies at law for a false statement;oi^ mateii^ fact may iheludeincarceration and an award to the Gity of treble-damages:
D. it is the City's policy IP make thi£ document available'toitrie public ton its Internet site and/pr uppn irequest-: Spme or all" pf the information provided On this^EDS and any attachments to this EDS may be' made available tp the public on the Internet; in response to a Freedom pf'infprmatipn'Ac.tjrpq'u otherwise. , By completing and signing this'EDS,.-the-Pis.clPsiri g Party waives and tejeases any possible rights or clairns which; it may have against the City in connection with the' public release ofinformation' cp.rit'ainPd-1'ii .this'E'P'S and also authorizes the Ciry tpi-ycrify the accuracy pf any information submitted in-this EDS.
Ei'tbe information provided ih this EDS must be kept current. In- the event pf change^ the Disclosing Party must supplement this'EDS up LP the tihic the 'City:takes actipn on the Matter. If the/Matter is a. pbotract being handled1 by die City's Depaftfn Services,- the Disclpsing Painty must-
update this,.EPS as the fcontfact requires. NOTE: With respect tp Matters subject'to ArtieI'e I;pf 'Chapter-1-23. of the Municipal Code(imposing PERMANENT J NELlGjlBJiLTf Y for certain specified pffcn.ses), the inforrndtion proVided herein regarding eligibility must'be kept current for a longer, period, as required by Chapter 1-23 and Section 2-154-020 pf the,Municipal Code.
The bis'^'lpsirig Party represents, and warrants that:
F: 1. The Pisclosing Parry is not dclin'quc.nt in the payment pf any ,tax' administered by the Illinois bepartment pf Reve'riue, hpr arethe pisclosing Party Pr its: ,Affiliated Entities delinquent in paying any 'fine, fee, tax pr p'ther charge; owed to the City. This" includes, but is npt -HrniiMiip,,all water Charges, sewef charges, license fee;s, parking tickets; property tax-e? or sale.s-itaxes.
iF;.2 If the Disclpsing Party is the Applicant the Disclpsing Party and its Affiliated Entities will-not use;, jio"t;perfnit their subcontractors' tp, use, any facility listed by the iliSV E:P-A; ort the federal, Excluded' .Parties 'List System ("EPLS"),maintained,by the.lJ. S^'Gerieral Services. Administration;
P,3 If the Discipsirig Party islhe Applicant,.the Disclosing Party will obtain from arty cOPtractors/subcontiaclpfs hired of to be hired in .connection with the:'Matter, eertificatidriseqUal in form and substance, "tp those in F41»: arid F.2. abpV.e and will npt^wi'thput the prior' Written consent of the-'.City, use any such -ephtractpf/sub.cpntractp hot provide such certifications pi' that the
Discjpsing Party has reason to be^cve has npt'prpyided Pf
Page, lfpf 13
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) arc true, accurate and complete as of the dale furnished to the City.
NHS Wrightwood Inc.
(Print or type name of Disclosing Party)
By: IJoU^lC (Sign here)
James K. Wheaton
(Print or type name of person signing) Vice President
(Print pr type title of person signing)
Signed and sworn to before mc on (date) 12. ■ - £b/ O at (Lap (j_County, _"ZT/_(state).
Notary Public.
Commission expires:
. OffiCtALSgAL .^NDRAGWIUJAMS
Page 12 of 13
CITY OF CHICAGO ECONOMJ C DISCLOSURE STATElvteNf' AND AFFIDAVIT
APPENDDC A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICLALS AND DEPARTMENT HEADS
TH|s 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 percent. It is not to be completedby any legal entity SVbich has only an indirect ownership interest in the Applicant.
Under Municipal,Code Section 2-154^015; the Disclosing Party must disclose, whether such Disclpsing Party of any "Applicable Fafty" o'r any. Spouse of Domestic Partner thereof cu^ently-has- a "familial relatiOT^ any elected pity official Of department head. A "fafm^alfelationship" exists:if,-as Pf the date, this, EpS.iis' signed,.the Disclosing Party or any "Applicable Party'5 of any Spouse Of Domestic Partner therepfTs Vejateditp. the mayory any aldcrmarij. the City clerk, the^city treasurer pr any city department head as spouse or domestic partner oras any of,the following, whether by blood Pr adoption: parent, child, brother or .sister, aunt or uncle, niece pr nepheW^grandparent,g^ndchild, famer-in-law, mquSer-in-law pf stepmother,,stepson or stepdaughter,,s^pbrothcr or stepsister of liatf-bjfother or-half-sister.
-jAppUcible Party" means (1) all executive pfficefs of the pisclp.sing>P^)h^-Usted in Section IhBT.a., if the Disclosing, Party is a.corporaripn; all partners of ,me Discipsihg Party, if the Disclosing Party is a, genera); ;p'afpiership; all general partners and limited partners of the DifectpsingPaftyi, if the Disclosing Party is a-limited partnership; all managers,, managing members and members: of the Disclosing Party, if the Disclosing Party;is: a limitedliability company; 0'aiV.p^cipal-ofBc^ni pTWppisclosidg^Paj^i'a^d(3)'any.peV^n.havmgmo*i«than: a 7.5\pcrpcn|ownership interest in the-OlsjiPsirfg'Pitifty. iiI^fic;ip^^pI^cf.fs, tri.eapS' th'e;presidem,- fchipf -operiting Pffi cef, executive directori ch i.ef nancial officer, treasurer pr .Secretary"bf a legal entity, or. any person exercising similar authority
'Does, die Disclosing Party pr any"Apph'cable Party1-' or any Spouse or Domestic Partn'er'thereof currently riayp:a ''familial relatipnsbip', with an ejected city official or department head?
[ ];Yes M
If ygs, please identify below,, (1) 'die name, and title pf such person;, (2)\tiie name, of the legal entity to which such[person is connected; (3)the name and title of the elected city 'PfQpial.pr department head tp whomsuch. person has a familial relationship;,and - (4)_ the precise nature of such familial rplatipnsbip.
Page 13 of 13