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This record contains private information, which has been redacted from public viewing.
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Type:
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Ordinance
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Status:
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Passed
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Title:
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Zoning Reclassification Map No. 9-K at 3911-3985 N Milwaukee Ave and 4671-4777 W Irving Park Rd - App No. 18266
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Topic:
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ZONING RECLASSIFICATIONS - Map No. 9-K
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FINAL FOR PUBLICATION SUBSTITUTE ORDINANCE BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. Title 17 of tie Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the B1-1 Neighborhood Shopping District symbols and indications as shown on Map No. 9-K in the area bounded by West Irving Park Road; A line 95.0 feet west of and parallel to North Kilpatrick Avenue; the east west public alley south of and parallel to West Irving Park Road; North Kilpatrick Avenue; North Milwaukee Avenue; SECTION 2: To those of a B3-2 Community Shopping District; , SECTION 3: Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the B3-2 Community Shopping District symbols and indications as shown on Map No 9-K in the area bounded by West Irving Park Road; A line 95.0 feet west of and parallel to North Kilpatrick Avenue; the east west public alley south of and parallel to West Irving Park Road; North Kilpatrick Avenue; North Milwaukee Avenue; SECTION 4: To those of a Business Planned Development. SECTION 5: This ordinance takes effect after its passage and approval; Common Address of Property: 3911-3985 North Milwaukee Avenue 4671-4777 West Irving Park Road i iwu, run ruBLIUAHUN BUSINESS PLANNED DEVELOPMENT NO. PLANNED DEVELOPMENT STATEMENTS The area delineated herein as Business Planned Development Number , ("Planned Development") consists of approximately 139,594 square feet of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Property") and is owned or controlled by the Applicant, CSD Six Comers LLC. The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance, the Property, at the time of application for amendments, modifications or changes (administrative, legislative or otherwise) to this Planned Development are made, shall be under single ownership or designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance. All applicable official reviews, approvals or permits are required to be obtained by the Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or alleys or grants of easements or any adjustment of the right-of-way shall require a separate submittal to the Department of Transportation on behalf of the Applicant or its successors, assigns or grantees. Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Plans. Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Departments of Planning and Development and Transportation. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of the Department of Transportation. All work proposed in the public way must be designed and constructed in accordance with the Department of Transportation Construction Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by the Department of Transportation. This Plan of Development consists of 15 Statements: a Bulk Regulations Table; an Existing Zoning and Land Use Map; a Planned Development Boundary, Sub-Area and Property Line Map; Site/Right of Way Adjustment Map; Landscape Plan; a Green Roof Plan; Building Elevations (North, South, East and West); and Floor Plans prepared by OKW Architects and Applicant. CSD Six Coiners LLC Address 3985-3911 North Milwaukee Avenue -1671-4777 West living Park Road Introduced- January 21, 7.015 Plan Commission. March 17.2016|1010| FINAL FOR PUBLiCATiO dated February 26, 2016, submitted herein. Full-sized copies of the Site Plan, Landscape Plan and Building Elevations are on file with the Department of Planning and Development. In any instance where a provision of this Planned Development conflicts with the Chicago Building Code, the Building Code shall control. This Planned Development conforms to the intent and purpose of the Zoning Ordinance, and all requirements thereto, and satisfies the established criteria for approval as a Planned Development. In case of a conflict between the terms of this Planned Development Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control. The following uses are allowed in the area delineated herein as a Business Planned Development; Sub Area A will allow the following uses permitted under the B3 Zoning District: Postal Service; Animal Services; Sales and Grooming (Shelter/Boarding Kennel only allowed as accessory use to pet store); Veterinary (Not including Shelter/Boarding Kennel); Construction Sales and Service including Building Material Sales (Excluding contractor/construction storage yard); Eating and Drinking Establishments including Restaurant, Limited; Restaurant, General; Outdoor Patio(Permitted if located at grade level and on rooftop); Food Catering allowed as accessory use to General or Limited Restaurant; Financial Services; including Automated Teller Machine Facility (no drive-thru permitted); Food and Beverage Retail including Liquor Sales (package goods) and Liquor Sales (as accessory use); Medical Service; Office; Personal Service; Repair or Laundry Service, Consumer including Dry cleaning drop-off or pick-up (No on-premise plant) and Coin-operated laundromat; Retail Sales, General; Entertainment Cabaret; Children's Play Center; Vehicle Sales including Auto Supply/Accessory Sales but no vehicle service allowed. Sub Area B will allow the use of a financial institution; Eating Drinking Establishments including Restaurant Limited; Restaurant, General; Outdoor Patio (located at grade level); Retail Sales, General and Office. On-Premise signs and temporary signs, such as construction and marketing signs, shall be permitted within the Planned Development, subject to the review and approval of the Department of Planning and Development. OffJPremise signs are prohibited within the boundary of the Planned Development. For purposes of height measurement, the definitions in the Zoning Ordinance shall apply. The height of any building shall also be subject to height limitations, if any, established by the Federal Aviation Administration. The maximum permitted Floor Area Ratio (';FAR") for the site shall be in accordance with the attached Bulk Regulations Table. For the purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations Table has been determined using a Net Site Area of 139,594 square feet. Upon review and determination. "Part II Review", pursuant to Section 17-13-0610 of the Zoning Ordinance, a Part II Review Fee shall be assessed by the Department of Planning and Applicant CSD Six Corners LLC Address: 3985-3911 North Milwaukee Avenue 4671-4777 West Irving Park Road Introduced January 21, 2015 Plan Commission: March 17,2016|1010| FINAL. FOR PUBLICATION Development. The fee, as determined by staff at the time, is final and binding on the Applicant and must be paid to the Department of Revenue prior to the issuance of any Part II approval. The Site and Landscape Plans shall be in substantial conformance with the Landscape Ordinance and any other corresponding regulations and guidelines. Final landscape plan review and approval will be by the Department of Planning and Development. Any interim reviews associated with site plan review or Part II reviews, are conditional until final Part II approval. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation, Fleet and Facility Management and Buildings, under Section 13-32-125 of the Municipal Code, or any other provision of that Code. The terms and conditions of development under this Planned Development ordinance may be modified administratively, pursuant to section 17-13-0611-A of the Zoning Ordinance by the Zoning Administrator upon the application for such a modification by the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. Specifically, the Applicant shall be allowed to eliminate the second story retail and replace with parking spaces administratively by the Zoning Administrator upon written request. The Applicant acknowledges that it is in the public interest to design, construct and maintain the project in a manner which promotes, enables and maximizes universal access throughout the Property. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. At the time of a hearing before the Chicago Plan Commission, all developments must be in substantial compliance with the current City of Chicago Sustainable Development Policy set forth by the Department of Planning and Development. The Applicant shall meet and exceed the minimum required areas of interior landscaping at the roof top parking per Chicago Landscape Ordinance with a goal of 100% of area not used for pedestrian pathways, vehicular use or mechanical space to be vegetated green space. Proof of a 5-year maintenance agreement to care for the vegetation on the roof shall be supplied and approved at time of Part II review. Planting of trees at the rooftop parking area will not be required. Applicant will exceed ASITRAE 90.1 2004 standards by 14%. Applicant1 CSD Six Corners LLC Address 3985-3911 North Milwaukee Avenue -'1671-4777 West Irving Park Road Introduced. January 21. 2015 Plan Commission. March 17.2016 FINAL FOR PUBUUAHU 15. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development ordinance lapse, the Commissioner of the Department of Planning and Development shall initiate a Zoning Map Amendment to rezone the property to B3-2 Community Shopping District Applicant CSD Six Coiners LLC Address 3985-391 I North Milwaukee Avenue 4671-1777 West Irving Park Road Introduced January 21, 2015 Plan Commission March 17.2016 FINAL FOR PUBLICATION BUSINESS PLANNED DEVELOPMENT NO._ BULK REGULATIONS AND DATA TABLE Gross Site Area: Area in Right of Ways: Net Site Area: Sub Area A: Sub Area B: Maximum floor Area Ratio: Max. FAR Sub Area A: Max. FAR Sub Area B: Setbacks: Maximum Building Height: Minimum Parking Spaces: Min. Parking Spaces in Sub Area A: Min. Parking Spaces in Sub Area B: 208,779 sq. ft. 69,185 sq. ft. 139,594 sq. ft. 119,644 sq. ft. 19,950 sq. ft. 0.9 1.0 .28 In accordance with Site Plan 52 feet 272 245 27 Bicycle Parking Spaces: Loading Spaces (Min. 10'x 50' per Code): 50 4 Applicant: CSD Six Corners LLC Property: 3911-3985 North Milwaukee Avenue 4747 West Irving Park Road Revised: February 26, 2016 LXIS IING ZONING MAP NTS SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS 3911 -3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD V N- f EXISTING ZONING AND STREET MAP 0 50' 100' 200' IfirliiBl t^>w!nm,taij SCALE: 1" = 200' I SHEET NO|1010|CPC DATE JEWEL GROCERY Cuyler Ave Cuyler Ave c SEARS/ COMMERCIAL COMMERCIAL COMMERCIAL Irving Park Rd CO < O 00 COMMERCIAL MIXED-USE Qj _i Ql o UJ Q. UJ 00 D Q UJ X' RESIDENTIAL RESIDENTIAL RESIDENTIAL. > < o RESIDENTIAL .£¦ PROPOSED DEVELOPMENT AREA U c c c V C, RESIDENTIAL N SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS 3911 -3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD EXISTING LAND USE AREA MAP NORTH KILPATRICK AVENUE PLANNED DEVELOPMENT BOUNDARY AND SUB AREA PLAN 0 25' 50' 100' SCALE: 1" = 100' SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS: 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD P.D. BOUNDARY, PROPERTY LINE/RIGHT OF WAY SHEET NO 3 DATE I CPC DATE 03 15.2016 j 03.17 2016 I If M I'm- t \f 1 \ < *••>&»»»« V»» J " > V NORTH:KILPATRICK AVENUE RIGHT-OF-WAY ADJUSTMENT SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS: 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD RIGHT OF WAY ADJUSTMENT | CPC DATl: | 03.17.2016 LANDSCAPE PLAN SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS- 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD GROUND LEVEL PLAN SHEET NO 7 DATE ¦ CPC DATE 0:i10 2C1G ! 03.17 2016 i I SECOND LEVEL PLAN SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD f U T.J GREEN ROOF PLAN SIX CORNERS - PLANNED DEVELOPMENT EXHIBI I S APPLICANT - CSD SIX CORNERS LLC ADDRESS 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD run sjUDUWinim COW co a: co a; <;p o 1-< > UJ _l LU r-C/D < UJ SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD F'fWrtL- o SIX CORNERS - PLANNED DEVELOPMENT EXHIBITS APPLICANT - CSD SIX CORNERS LLC ADDRESS: 3911-3985 NORTH MILWAUKEE AVE 4671-4777 WEST IRVING PARK ROAD BUILDING ELEVATIONS SHEET NO 12 DATE 03 15 2016 CPC DATE 03 17 2016 DlPARTMENT OF PLANNING AND DEVELOPMENT CITY OF CHICAGO MEMORANDUM Alderman Daniel S. Solis Chairman, City Council Committee on Zoning David L. Reifman Secretary Chicago Plan Commission March 18, 2016 RE: Proposed Planned Development for property generally located at 3911 North Milwaukee Avenue. On March 17, 2016, the Chicago Plan Commission recommended approval of the proposed planned development submitted by CSD Six Corners LLC. A copy of the proposed planned development is attached. I would very much appreciate your assistance in having this introduced at the next possible City Council Committee on Zoning hearing. Also enclosed is a copy of the staff report to the Plan Commission which includes the Department of Planning and Development, bureau of Planning and Zoning recommendation and a copy of the Resolution. If you have any questions in this regard, please do not hesitate to contact me at 744-5777. cc: Steve Valenziano PD Master File (Original PD, copy of memo) S 00G0 2 fORTH LASALLE STREET. ROOM 1000. CHICAGO, ILLINOIS c o CO O NORTH KILPATRICK AVENUE cj CD < 00 o PQ CD < £ si LU f K |1010|5} y a. jo > CD Q CD *o o (N x U < s O CO CD 3 2: > < > UJ UJ c/5 LU BHHIH < . CO 00 |, I, <° S' O - u - HHHE3 a. O : S : or.' a. ' to — 10 h ID CD Tf h- r) t— oj I— cm \- V % v < > Q cr at: rr UJ < UJ h-00 UJ X H o § 00 s ^ V* ^ S HI „ SS O ' CL ' M m Z < u» "S to 1 ? §ggB .3 Era, B o o 53 o Oh H 5 O 3 => 00 CQ o < u o a! ^ o O' O ." o z^zg OH O O P 3 Q-i ' < lo i |1010|CO U < s a: m > o -tl CO a s- o U * y3 z p o J3 H C/j o H +-» .CD W GO a T-H PQ o I— < > UJ I LU X I— O CO si a: a. Pi-SS 5 o Car |1010|HZ O < U < . CD CD o 4-» Qrr: CD Q_ O q2 Ph z o CM O < s s-o u 55 o Ph J3 5 O < u • T—( CD CD -i—» O CD Oh < i— LU UJ z: UJ > < UJ UJ sz ZD < o CM U < 4> G im o O 53 o Cm 5 *r O a; < U FINAL REPORT to the CHICAGO PLAN COMMISSION from the DEPARTMENT OF PLANNING AND DEVELOPMENT MARCH 17, 2016 PROPOSED PLANNED DEVELOPMENT (APPLICATION NO. 18266) CSD SIX CORNERS, LLC 3911 NORTH MILWAUKEE AVENUE Pursuant to the provisions of the Chicago Zoning Ordinance, Title 17 of the Municipal Code of Chicago, the Department of Planning and Development hereby submits this report and recommendation on a proposed Planned Development for your review and recommendation to the Chicago City Council. The application was introduced to the Chicago City Council on January 21, 2015. Notice of this public hearing was published in the Chicago Sun-Times on March 2, 2016. The Applicant was separately notified of this public hearing. The property is identified as 3911 N. Milwaukee Avenue and is located in an area known as Six Corners. The applicant, CSD Six Corners" LLC, proposes to create a planned development consisting of two sub-areas. Sub-area A will be improved with a two-story commercial building comprised of approximately 101,000 square feet of retail space. Sub-Area B would contain an existing one-story drive through bank facility. This application has been submitted as a mandatory planned development pursuant to section 17-8-0510-A of the Chicago Zoning Ordinance which states that planned development review and approval is required for any building in a B or C zoning district which is to be occupied by retail sales-related uses with a gross floor area of 75,000 square feet or more. FINAL SITE AND AREA DESCRIPTION • ¦ —\.~. +A • --•.V -...•I .• --I i 1 FINAL PROJECT BACKGROUND AND DESCRIPTION The subject site consists of approximately 139,594 square feet and is comprised of two parcels each which will become its own distinct sub-area. Sub-Area B is 19,950 square feet and is currently improved with a one story bank facility, no changes are proposed to this sub-area as part of the proposed planned development. Sub-Area A is 117,732 square feet and is currently improved with one and two story office buildings which will be demolished to make way for a two-story commercial building containing approximately 100,000 square feet of retail space and approximately 245 parking stalls on the roof of the structure. DESIGN, ACCESS AND CIRCULATION FINAL Department of Planning and Development city of chicago 3911 NORTH MILWAUKEE AVENUE PROPOSED BUSINESS PLANNED DEVELOPMENT RESOLUTION WHEREAS, the Applicant, CSD Six Corners LLC, filed this application requesting to establish a Business Planned Development for the property generally located at 3911 North Milwaukee Avenue to aiiow for the construction of a one-story commercial building; and, WHEREAS, pursuant to the Chicago Zoning Ordinance, Section 17-8-0510-A, Plan Commission review and recommendation is required due to the proposed development including more than 75,000 square feet of gross floor area dedicated to retail use; and, WHEREAS, the Applicant's request to establish this Business Planned Development was introduced to the City Council on January 21, 2015; and, WHEREAS, proper legal notice of the hearing before the Plan Commission was published in the Chicago Sun-Times on March 2, 2016. The Applicant was separately notified of this hearing and the proposed zoning application was considered at a public hearing by this Plan Commission on March 17, 2016; and, WHEREAS, the Plan Commission has reviewed the application with respect to the provisions of the Zoning Ordinance and finds that the proposal will be consistent with said provisions; and, WHEREAS, the Department of Planning and Development recommended approval of the application, with the recommendation and explanation contained in the written report dated March 17, 2016, a copy of which is attached hereto and lade a part hereof; and, m: WHEREAS, the Plan Commission has fully reviewed the application and all informational submissions associated with the proposed Business Planned Development, the report and recommendation of the Commissioner of the Department of Planning and Development and all other testimony presented at the public hearing held on March 17, 2016, giving consideration to the Zoning 121 NORTH LASALLE STREET, ROOM 1000, CHICAGO, ILLINOIS 60602 FINAL Ordinance. NOW, THEREFORE, BE IT RESOLVED BY THE CHICAGO PLAN COMMISSION: THAT the final application dated March 17, 2016 be approved as being in conformance with the provisions, terms and conditions of the corresponding zoning application; and, THAT this Plan Commission recommends approval to the City Council Committee on Zoning, Landmarks and Building Standards of the final zoning application dated March 17, 2016; and, THAT the above-stated recitals to this resolution together with the report of the Commissioner of the Department of Planning and Development be adopted as the findings of fact of the Plan Commission regarding this application. BPD#: Approved: March 17, 2016 121 NORTH LASALLE STREET, ROOM 1000, CHICAGO, ILLINOIS 60602 FINAL The existing bank facility is finished in face brick and the front facade includes a large transparent aluminum and glass storefront system. The proposed retail facility project has been designed to make sure the long street frontages do not read as a large monolithic slab but instead a series of more intimate retail experiences. The facades make use of a number of different building material types such as precast panels, glass and aluminum storefront systems, exterior rain screens, fiber cement panel systems, and cast stone. The parking located on the roof is screened by parapet walls that extend up at varying heights to ensure that the headlights and most of the vehicles are screened from view to pedestrians. The proposed color palette for the project is a series of whites and grays accented by the cast stone and wood looking rain screen system. Irving Park Road and Milwaukee Avenue are designated as Pedestrian Streets thus the parking and loading will be accessed from Kilpatrick Avenue. A two-way traffic ramp will take vehicles up to the roof top and also back down from the rooftop at this location. In addition once users have reached the rooftop there will be access to three elevators and staircases that lead back down to the retail areas. Accommodations for 50 bicycle parking spaces will also be made available on site. The developer is also in negotiations to re-locate a divvy bike parking station to the city parkway adjacent to this development. LANDSCAPING AND SUSTAINABILITY The entire planned development will be compliant with the requirements of the Chicago Landscape Ordinance specifically in terms of parkway trees. The parking located on the roof top will meet an equivalent amount of green spaces as would be required if this were a surface parking lot, however, due to the rooftop location parking lot trees will not be required. The subject site will be designed to be in compliance with the current City of Chicago Sustainable Development Policy. The Applicant shall meet and exceed the minimum required areas of interior landscaping at the roof top parking per Chicago Landscape Ordinance with a goal of 100% of area not used for pedestrian pathways, vehicular use or mechanical space to be vegetated green space. Proof of a 5-year maintenance agreement to care for the vegetation on the roof will be submitted to the department at the time of Part II review. Planting of trees at the rooftop parking area will not be required. Applicant will exceed ASHRAE 90.1 2004 standards by 14%. BULK/USE/DENSITY The proposed retail project as previously described has a current maximum allowable Floor Area Ratio (FAR) for the proposed underlying zoning district (B3-2) of 2.2; the proposed planned development will be limited to a maximum of 0.9 FAR. The proposed project will have a maximum building height of 52'-0". The proposed planned development will maintain setbacks that are in substantial compliance with the requirements of the B3-2 zoning designation. All remaining FINAL bulk, use and density items will be in substantial compliance with the stipulations of Section 17-3-0400 for B3-2 zoning districts. RECOMMENDATION The Department of Planning and Development has reviewed the project materials submitted by the Applicant and compared this proposal to the requirements of the Chicago Zoning Ordinance and existing development in the community. The area around this project is composed of a mixture of various uses including commercial, retail, and residential uses and is accessible from public transit. Based on that analysis, DPD has concluded that this proposal is appropriate for this site and supports this development for the following reasons: Promotes economically beneficial development patterns that are compatible with the character of existing neighborhood (per 17-8-0103), as evidenced by the design of the project, and the fact that the proposed uses are in context with the character of the adjacent properties and also meet the needs of the immediate community; Promotes transit, pedestrian and bicycle use, ensures accessibility for persons with disabilities and minimizes conflicts with existing traffic patterns in the vicinity (per 17-8-0904-1-2, 3 & 4), as evidenced by the site's close proximity to public transit in the form of various CTA bus lines, CTA Transit Lines and various Metra stations which are located in close proximity to the proposed development; the accessibility accommodations made on-site for the building users; pedestrian and bicycle ingress and egress options provided to the building users in the form of 50 bicycle parking stalls, and lastly, ensuring that the design of the site works within the confines of the current existing traffic patterns at the site and creates little or no adverse impact to those patterns; All sides and areas of the buildings that are visible to the public should be treated with materials, finishes, and architectural details that are of high-quality and appropriate for use on primary public-right-of-way-facing fagade (per 17-8-0907-A-4), as evidenced through the information contained within this report, as shown on the elevations in the exhibits for this planned development, and the corresponding proposal renderings; The proposed development is consistent with the guiding principles listed in the Six Corners Economic Development Master plan, specifically the proposal seeks to attract more retail stores and business to the six corners area that will appeal to the diversity of households in the area, the new construction will be an upgrade in building facades and storefronts over the previously vacant office building located on site, this site was indicated to be a key opportunity site for redevelopment in the area, and lastly that the proposed development seeks to enhance the pedestrian environment by creating plaza spaces that can be used as sitting areas and gathering spots for pedestrians and by providing a centrally located area to park FINAL vehicles, while a shopper can then safely circulate around the shopping district and then later return to their vehicles. The project meets the purpose and criteria set forth in the Chicago Zoning Ordinance and its adoption would not have any adverse impact on the public's health, safety or welfare: Per 17-13-0308-C, the proposed development is compatible with surrounding developments in terms of land use, as well as, the density and scale of the physical structure. Per 17-13-0308-D, the proposed underlying zoning for this planned development is B3-2 and is similar to other business and commercial zoning districts, both adjacent to this site and in the immediate area. Per 17-13-0308-E, the public infrastructure facilities and City services will be adequate to serve the proposed development at the time of occupancy and the project will comply with the requirements for access in case of fire and other emergencies. The proposed project has been reviewed by the Mayor's Office for People with Disabilities and the Department of Transportation and all requested changes have been made. Copies of this application have been circulated to other City departments and agencies and no comments have been received which have hot been addressed in the application. Based on the foregoing, it is the recommendation of the Department of Planning and Development that this application for the establishment of a Planned Development be approved and that the recommendation to the City Council Committee on Zoning Landmarks and Building Standards be "Passage Recommended." Bureau of Planning and Zoning Department of Planning and Development RECEIVED MAR 1 7 2016 Initial: Lp AMENDED CITY OF CHICAGO APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE ADDRESS of the property Applicant is seeking to rezone: 3911-3985 North Milwaukee Avenue/4671-4777 West Irving Park Road Ward Number that property is located in: 45 APPLICANT CSD Six Corners LLC ADDRESS 980 North Michigan, Suite 1280 CITY Chicago STATE IL ZIP CODE 60611 PHONE 312-377-9111 EMAIL peisenberg(5)clarkstreet.corrCONTACT PERSON Peter Eisenberg Is the applicant the owner of the property? YES X NO If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed. OWNER Same as Applicant ADDRESS CITY ' STATE ZIP CODE : PHONE EMAIL CONTACT PERSON If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information: ATTORNEY Kevin Wolfberg, Schain Banks ADDRESS 70 West Madison, Suite 5300 CITY Chicago STATE __IL ZIP CODE 60602 PHONE 312-345-5700 FAX 312-345-5701 EMAIL kwolfberg(5)schainbanks.com If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements. CSD Six Corners Member, LLC Peter Eisenberq Perry Weinstein, Trustee Fritz Duda, Jr _Bixby Bridge Fund II LLC Blackfriar Corp Carol Grigor Collins Family Limited Partnership JEC Investments, LLC J^mes Kurszweil Hulina Family Limited Partnership Andrew Stein Clark Street Development LLC E. Thomas Collins. Jr Flatiron Investments Company LLC Sylvia Doyne Collins JMK Interests. LLC John Collins Keith Colburn Richard Colburn On what date did the owner acquire legal title to the subject property? June 3, 2014 Has the present owner previously rezoned this property? If yes, when? No Present Zoning District B1-1 Proposed Zoning District B3-2 then to Business Planned 139,594 square feet Development Lot size in square feet (or dimensions)__ . Current Use of the property Vacant and listing financial institution Reason for rezoning the property Retail Center with parking and financial institution Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC) The proposed use is a ? story vertical rptail r-pntpr containing aprny nnn gf|iiaro fppt nf retail with 245 parking spaces. The Planned Development will also include a 5,000 square foot financial inslitution containing 27 parking spaces On May 14th, 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the Jot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information) NO X COUNTY OF COOK STATE OF ILLINOIS I. Peter Eisenberq being first duly sworn on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct. Signature of Applicant Subscribed and Sworn to before me this I U day of M-c^r-ftU 20, 1 (/ , Notary Public Date of Introduction:. File Number: Ward:. CJTV oi< ci(icac;o ECONOMIC DISCLOSURE STAT EM ENT AND AFEI DAVIT SECTION 1 GENERAL INFORMATION A. Legal name of the. Disclosing Party submitting this EDS. Include, d/b/n/ if applicable: JMK Interests, LLC Check ONE of (he following three boxes: Indicate whether the Disclosing Party submitting this EDS is: [ ] the Applicant OR ^ 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: CSD Six Corners LLC OR 3. [] a legal entity with a right of control (see Section II. B.l.) Slate the legal name of the entity in which the Disclosing Party holds a right of control: ' B. Business address of the Disclosing Party: 980 North Michigan, Suite 1280 Chicago, IL 60611 Telephone: (312) 377-9111 Fax: Email: Jcollins@clarkstreet.com
Name of contact person: John Collins
Federal Employer Identification No. (if you have one): __• •
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):
Zoning Amendment for property located at 3911-3985 North Milwaukee Avenuo; 4671-4777 West Irving Park Road .
G. Which City agency or department is requesting this EDS? DPP ¦_
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract // _
Page I of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes [ ] No
1. indicate the nature of the Disclosing P;iriy: Person
£ j Other (please specify)
Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership Trust
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
Illinois
3. For legal cntities.not organized in the State .of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[]Ycs []No • J/J N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names andititles of all executive officers and all directors of the entity.-NOTE: For not-for-profit corporations, also list below all members, if any, which arc legal entities. If there are no such members, write "no members." For trusts, estates'or other similar entities, list belo w 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, mahager.or any other perspn.or entity tthat controls the day?to-day.managcment of the Disclosing^Pnrty. NOTE: Each legal entity.listed below must submit an EDS on its own behalf.
Name Title
James Kurtzwell Manager and sola 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,
Page 2 of 13
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 2-1 54-030 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
James Kurtzweil 980 N. Michigan, #1280, Chicago, IL 60611 100%
SECTION III -- BUSINESS RELATIONSHIPS WI TH 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?
[]Ycs 0No.
If yes, please identify below the namc(s) of such City elected official(s) and describe such rclationship(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 ns 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, oh 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 cither ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
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)
y\ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under 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 br indirectly owns 10% or more of the Disclosing Parly been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [/[ No [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes," iiaHhe person 'entered into a court-approved agreement for payment of all'support owed and is the person in compliance with that agreement?
[ ] Yes ¦ pW ' ' ,. 1
FURTHER 'CERTIFICATION S , . .'
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(v/liich the Applicant should
consult for'defihed "doing business") and legal requirements), if the'pisclpsiiig.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 deccit'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.
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 H.B.l. of this EDS:
a. arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
I), 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;
arc 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 13.2.b. of this Section V;
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
c. havc.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 conncctipnyyi.th the MattQr^inpludihgJbjit not limited.to all persons or.le'gal entities disclosed under. Section IV, "Disclosure of .Subcontractors and Other. Retained Parties");
any "Affiliated Entity"-{meaning a^person or entily.that, directly oriindirectly: contrpls 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 manageincut 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 terra Aiffilialcd 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 Parly, nor any Contractor, nor any Affiliated Entity of cither the Disclosing Party or any Contractor nor any Agents have, tim ing 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 Ma tier:
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;
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; of
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
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
NcithcY 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 governmentas 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.
Ncith5|r.^Ke^iselo*sirif>Pkrry nor", any'Affiliated Entity is listed dn^aajTbfthc fblloHymglisfs
maintained by" the'Officc'o'f''Foreign 'Assets Control of the U.S. Department of the Treasury or faic
Bureau of Industry and Security bf;thvc^ft the" Specially
Designatedttfatio'hals Lustj^tie^efiiea* -Persons:L'isi, the UnverifiediListi',thV:Entity':L,isi€n,d^fc
DcbarrcdTiistV - •* •••'•'•*' :- ' ; '
TheUDi'sclosing^PaftyXiri'dpfStart Chanters 2-55 (Legislative In's^ectdrGcneml); 2^56 (Inspector General) and 2-156 (Govcrn'mcntaTEthicsj^f the MunicipaTGodc;
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
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.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 1 2-month period preceding the execution date of this P.DS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given; at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of loss than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is [/\ is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing'Party pledges:
"We arc 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. Wc 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):
Page 7 of 13
Jl" the letters "NA," the won! "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.
In accordance with Section 2-1 56-110 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 f/No'
NOTE; If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property 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.
Docs the Matter involve a City Property Sale?
[]Ycs f/jNo
If you checked "Yes" to Item"D.l., provide the names and business addresses of theCity officials or employees having sudi,interest and identify, the nature of such interest:
Name Business Address Nature of Interest
r—¦—¦ w ¦ ¦ ¦¦ — :¦ a. ... •——j-yry^ ¦ a ¦. "—
4. The Disclosing Tarty, farther 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 cither 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
Page 8 of L3
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
_1. The Disclosing Party verifies that the Disclosing, Parly 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:
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 arc 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):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the.wofd '."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 lo influence or attempt lo 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.
Page 9 of 13
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.!, and A.2. above.
The Disclosing Party certifies that cither: (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 engagc in "Lobbying Activities".
If fhe'Disclbsing 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 m ake such certifications promptly available lo the City upon request.
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?
[]Ycs []No
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract-CompH or the Equal Employment Opportunity Commission all reports due
undertfi^ppTicSbfe'iHiing -requirements?'
[ ] fcsU []No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
¦[*\ Yes " [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII-- ACKNOWLEDGMEN TS, CONTRACT INCORPORATION, COM PLIANCE, 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 arc 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."-
13. 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 w w w. cityo fc h ic ago ¦ org/ E th ics. and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
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 br'be'void or voidable, and the City may pursue any remedies under the contract or agreement (if not'res'cin^de'd or void), at law, or in equity, including terminating the Disclosing Party's participation in the?Matt'cr 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 lhe.City .of;trcble damages,
It is the City's policy to make this.document available to the public on its Iuterriet'sitci'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 A^ctsreq^
otherwise. By completing and signing this EDS, the Disclosing Party waives and rcleases.any':p*p,ssible
rights or claims which it may have against the City in connection with the public r,elcase,of.information
contained in this EDS and also authorizes the City to verify the accuracy of any°infbMg'tib'n?SjipiHittcd
in this EDS. '' '''
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract, being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to.Matters subject to ArticleT;of Chapter 1-23 of the Muhi'cip;ah$:pde (imposing PERMANENT INELIGIBILITY for certain specified offenses), the informatioiv'prov'ided 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:
Page 11 of 13
F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor arc 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 foes, parking tickets, property taxes 01 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 Early 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 wilt not, without the prior written consent-of the City/us'c any such contractor/subcontractor that docs'not provide such certifications or that the Disclosing Parly has reason to believe has not provided or cannot provide truthful certifications.
• NOTE:"If the Disclosing Parly cantiot certify as to any of the items in F. 1., F.2. 6r-F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
^U^adejrjpe.nalt^.pf(perjury, the person-signing below: (1) warrants-that he/she is authorized to execute . ;t1iis,£iDS,certifications ^ in this EDS and Appendix A (inapplicable) are true, .accurate
and cbmplete^^^ '
(Pfint;'or type name of Disclosing Party)
-¦¦ ^&gri?iiere) ' JarhesjKurtzvvel ,,
¦'Manager and sole member
(Print of type title of person signing)
Sigh'&d arid sworn to before mc.on (dato) CH 1 t*)^ ( [c. ¦ICounty, ^-\\ ,'.^-^Jstatc).
- r\ Notary Public
Commission expires: QCj t'l L( j ) *1 •
Page 12 of 13
vm. OFFICIAl'.SEAl ' Notaiy Public. StolVoflltlrtoU -My Corhmlt'il6h;Explt«t Ap'fll 14.-2017.
MM IM II "•' ¦ ' " ¦' '"lH I II I ¦ IMlWjl'l
CITY 01" 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 (n) the Applicant, and (b) any legal entity which lias 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 Patty or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this 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 lLB.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.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ]Ycs J/] 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 APPENDIX B
BUILDING CODE SCOPFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is (o be completed only by (n) (lie Applicant, and (b) any legal entity which lias 11 direct ownership interest in (lie Applicant cxcccdlug 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an Indirect ownership Interest in the Applicant.
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identi fied as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ 3 Yes txTNo
-If the Applicant isn legal entity publicly traded on any exchange, is any officer.or director of the Applicant identified as a building "code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Ycs [ ]No "b/] Not Applicable
3. If yes to (I) or (2) above, pleaseidentify below the name of the person or legal entity
identified as q-building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent.code violations apply.
JELLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, ANTJ THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTTFIGATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3985 N MHwaukee/4671-4777' W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that
he/she is authorized to execute this EDS rccertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as of the dale furnished to the City and continue to be true,
accurate and complete as of the date of this rccertification, and (3) reaffirms its
acknowledgments.
JMKInterests, LLC Date: c3 f I^IT-OIIp
(Print or type legal name of Disclosing Party)
Print or type name of signatory:
James Kurtzwoil
Title of signatory: Manager and Sola Member
Signed and sworn to before me on [date] - \ ft < \ Lt , by
'ZVCix*. p J^ir4-t.^//. at _JQJ!i£Uc. County, ~\~L—
QjAx^iJl C^M* s/i ^ <3> Notary Public.
Commission expires: • / ^/ « 1 *"7 .
Vcr. 11-01-05
CITY OK CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of Ihc Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
C. Thomas Collins, Jr. Iirevocablc Children's Trust dated 04/10/96 on bohslf o! Klmboily Anno
Check ONE of the following three boxes.
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
\/\ 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: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (sec Section II.D.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: 960 North Michigan, Suite 1280
Chicago, IL 60611
Telephone: (312) 377-9111 Fax: _ _ Email: JcolHns@clarkstreet.com
Name of contact person: John Collins
Federal Employer Identificationi No. (if you have one): .
Brief description of contract,transaction or other undertaking (referred to below as the "Matier") to which this EDS pertains. (Include project number and location of property, if applicable):
Zoning Amendment for property located at 3911-3985 North Milwaukee Avenue; 4G71-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS? DPP
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification U and Contract it
Page 1 of 13
SECTION II - DISCLOSURE Of OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?
1] Yes , []Nfo [~~| Other (plea sc specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable: N/A
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?
[]Ycs [JNo ,J/]N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ErTflTY:
I. List below thcfull 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 arc legal entities. If there are no such members, write "no members." For trusts, estates If the entity is a general partnership, limited parhiership.Jimited.liability .company, limited liability partnership or joint venture, list below the name and title of each gencrarpartner, managing member, manager:or;ahy,odier person or entity that controls thc dayrtor.day.managerncnt of the Disclosing Party. NOTE: Each legal entity, listed below must submit an JsDS on its d\vn;.behalf.
Name Title Perry Wolnsteln Trustee
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,
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, stale "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 lo achieve full disclosure. 1
Name Business Address Percentage Interest in the
Disclosing Party Kimberly Anne Collins 980 N Michigan Avenue, #1280, Chicago IL C0611
SECTION 111-- 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 E/jNo
If ycs,;plcasc identify below the name(s)of such City elected offlcial(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 cither ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
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)
\fi Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V — CERTIFICATIONS : .
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under 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 L/^No [] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes," lias tie person entered into a court-approved agreement for p'aymcnlof^'aii'su'^pbM'bwcd and is the person in compliance with that agreement?
[]Yes '' . [ ] No , - • ->¦'¦"
FURTHER CERTIFICATIONS V '"
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g.-,'"doihjg'busincss") and legal rcqmrcmehts)y tfihcJbisj^|!stng I*arty submitting this ED.S is'theApplicanVand is doing business wim me'City, itien''iHc' pfscYo'siri'g Party certifies as follows: (i) neither the Applicant nor any controlling pcrsbn'is currently inclicted or charged with, or has admitted guilt of, or'has ever been convicted of, 6 rp laced under supervisiofiTor, 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; ahd (ii) the Applicant understands and acknowledges that compliance with Article I is a fcdhtinmngVequircment 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.
Page 4 of 1 3
2. The Disclosing Party and, if the- Disclosing Parly is a legal cniiiy, all of those persons or entities
identified in Section U.R.I, of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not. within a five-year period preceding the dale 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, slate or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, stale or local) terminated.for cause or default; and
have not, within a five-year period preceding the;datc 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 "Gontractor,!v(meaning any contractor or subcontractor used.by the Disclosing Party in connection with, the'Matter, including but not limited to.all pcrspns.or.lcgal entities disclosed under Section JY^-'iDisclosurc of Subcontractors and O.thcr.Rbtained .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: interlqcking'Tnanagcmcnt or ownership; identity of interests among ¦family members, shared facilities and equipment; common use of employees; or organization of aibusincss .entity.foilowing.thc ineligibility of a business entity to do business with federal or state or local government, including the City, using-substantially the same management, ownership, or principals as the ineligible entity); with respect.to Contractors, the term Affiliated 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 Part)-, no; any Contractor, nor any Affiliated Entity of cither the Disclosing Pany or any Contractor nor any Agents have, during the five years before the date this F.DS 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:
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 Stale of Illinois, or any agency of the federal government or of any state or local government in the United Slates of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in rcslraiul of freedom of competition by agreement to bid a fixed price or otherwise; or
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
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neithcr'thc Disclosing Party,!fA{filiatcd Entity or Contractor, or any of thcircrriplbyecs, officials, agents or partners, is barred from contracting with any unit of state or local, government's 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 TLCS 5/33E-4; or (3) any similar offense of any state or of the United States of. America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nbr'any Affiliated Entity is listed on any of thc'foUowihg lists maintained by the Office o"f>For6ign?A'sscfs' Control of-the:U.S. Departmcritof tlie nYe'asury or thc Bureau of Industry and Sccurity>p^
Designated Nationals List, thc>D'ciiibd PcrsbnsiList, the Unverified List; thc^htityList arid the
Debarred List: " ¦ -K:'- ¦¦ ¦ ¦¦: i-----^
' The Dlsclosing-Party understands and shall comply with the applicable requirerriehts of Chapters 2-55 (Legislative inspector Gcncrar)',-:2-5'6 (Inspector General) and 2-156 (Govcrrimeri'taPEthics)-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
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.
ft. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or ''none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this P.DS, to an employee, or elected or appointed official, of the City of Chicago, for purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A".or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A ~
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is (/] is not
a "financial jnstitution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc 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):
Page 7 of 13
If the loiters "NA." the word "None," or no response appears on vhc lines above, it will be-conclusively presumed that the Disclosing Parly certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 of the Municipal Code: Docs 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?
[]Ycs L/]No
NOTE: If you.cb.eckcd "Yes" to Item D.l., proceed to Items D.2. and D.3. Tf you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected officialor 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 docs not constitute a financial interest within^fhe meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes ¦ f/j No
If you checked "Yes" to Item D.l., 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 cither 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
Page 8 of 13
comply with those disclosure requirements may make any contract entered into with the City in connection with the Mailer voidable by the City.
^ I. The Disclosing Party verifies that the Disclosing Parly 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 thai provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies thai, as a result of conducting the search in step 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:
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 arc 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):
(If no explanation appears or begins on the lines above, or if the letters "NA" of if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO p'cfsdns'bf 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.
Page 9 of 13
3. The Disclosing Pany 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.
The Disclosing Party certifies that cither: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1 986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 19S6 but has not engaged and will not engage in "Lobbying Activities".
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 .
13. 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?
[]Ycs []No If "Yes," answor^thc three questions below:
Have you developed and do you have on file affirmative 'action programs; pursuant to applicable federal regulations? (Sec 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with tlie Joint Reporting Committee, the Director of the Office of Federal Contract Compliancc.Programs, or'the Equal Employment Opportunity Commission all reports due under, tlie ap'piicable'filihg requirements?
[;] Ycs; ":" ' [ ] No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[] Yes []No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, CO M I'LI AN CE, PEN A L IIES, I) ISC LOS IIR E
The Disclosing Party understands and agrees that:
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 arc 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.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain ditties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances atid a training program is available on line at www.cityofchicaRo.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 M.
Sedgwick St., Suite 500, Chicago, IL 606.10, (3 12) 744-9660. The Disclosing Party must comply fully with the applicable ordinances. ,
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any conttact or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue aiiyrcmcdics 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 ah aWafd to the City of treble damages.
It is the City's policy to make this document available to die 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.
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:
Pngc 11 of 13
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 tlie 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 th'e'fcdcral 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
contractprs/subepjU hired or to be hired in connection with.the .'Mattercertifications equal in
form andjsubstancc to those in F.l. and F.2. above and will not, wilhouHbc pnor?,writlcn consenl of the City, use any such contractor/subcontractor that docs not provide such.ccrtifications or that the Disclosing Party has reason to believe has not provided or cannot provid'e^tratU'ral'ticrtifications.
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:pcrjiiry,-thc person signing below: (1) warrants that he/she is authorized to execute
this^pS.and^pRcndi onlbehalf of the-Disclosing-Partyj-arid(2) warrants that-all ¦
certifications and;statements contamed.in.rthis EDS and Appendix A (inapplicable) arc true, accurate
and complete.fls.^;the,date,fornishe
E. TtaTui CoU-.l,Jr. trMUtf* Cli^Wi Trxltctt [Wivn en t»MMiaT.Sii(Print^f^tojJ'.nanje^of p|scIosing Party)
•(Sl^jlbfr Eerry.Welristaln.
(Pfiril'olr^e harric'of persoh'sighirig): Trustee
(Print or type title .of person signing)
Signed and,JT\vprh to before me,oh (date) ^
at ^- ^IWHn^- Notary Public
fZn f'l „ I NOTAIWPUBLIC;.;StATE6FTl.UNOIS 'l
n ¦ ¦ „v„,r„„. /Hi I i; My Ckimmlcsldn Expires07/09/2017.
Commission expires: // /// / - Wwmwrfmw^wm™^^
Page 1.2 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to he completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 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 dale diis 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, mothcr-ih-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 U.B.l.a., if the Disclosing Party is a corporation; all partners of tlie 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 tlie president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar audiority. ¦
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or departmenthead?
[ ]Ycs L/]No
If yes, please identify below (I) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) tlie 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 APPENDIX li
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is lo be completed only by (a) Hie Applicant, and (b) any legal entity which has » direct ownership Interest in the Applicant exceeding 7.5 percent, (nn "Owner"). It Is not lo be complctcd'by nny legal entity which has only an indirect ownership Interest in the Applicant.
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner, identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ JYcs t>fNo
If the Applicant is a legal ent ity publicly traded on any exchange, is any officer or director of the Applicant identified as.a building bode scofflawor problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ JYcs [ ]No ^J] Not Applicable
If yes to-(l) or (2) abovc,.pleasc identify below the name of-thc person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent.code violations apply,
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDTX B IS INCORPORATED BY REFERENCE UNTO, AND MADE A PART'OF, THE ASSOCIATED EDS, AND THAT THE REPIUSSENTATIOl^S MADE IN THIS APPENDIX B ARE • SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you lo recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
DECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
Tin's rcccrtificntion is being submitted in connection with 3911 -3985 N MllwoukooMB7-1 -4777 W Irving Perk Road
[identify the Matter]. Under penalty of perjury, the person signing below: (I) warrants-thai
he/she is audiorized to execute du's EDS rccertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as of the date furnished to the City and continue to be true,
accurate and complete as of tlie date of this rccertification, and (3) reaffirms its
acknowledgments.
E. Thomas Collins, Jr. Irrevocable Children's Trust dated 04/10/06 on behalf of Klmborly Anne
(Print or type legal name of Disclosing Party)
(sign hire) Print or type name of signatory:
Pony Welnstoln
Tide of signatory;
Tmsloo
Ver. 11-01-05
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 sighed, the Disclosing Party or any "Applicable Party or anyiSpouse or Domestic Partner thereof is related to the mayor, any alderman, the city cleric, the city treasurer or any city department head as spouse or domestic partner or as aiiy of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, .grandparent, grandchild, father-in-law, mothcr-in-law, sofiMh-iaw, daiighler-=in-iaw, 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 tlie Disclosing Party, if the Disclosing Party is a general partnership; all general parmcrS-and;Iinutcd partners ofme.DjscIosing Party, ^ limited partiicfship; all managers, managingrnerhbers and members ofvthc Disclosing'P4rry,;if>the Disclosing Party is a Ufhlted liability company; (2) all principal officers of'theDisclosirigiPartyr.and'C^) any person having more than a 7.5/percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief op'^ting officer,, executive director, chief financial officcr,'-fi^br^^r^cretaiy: of a -legal entity pr-ariy person cxetclsing.similar authority. •
TJfocs the DisciosingParly or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "farmlial relationship." with, an elected city official 6>.4^ar^iat*hea^?
[ ] 'Yes F/]*No
If ycSi please identify below (il )'the name and title of such person/.'^ cfitity to which
such person is connected; (3) the name and title of the clectcd city official of d^aftmerif head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM-LANDLORD CERTIFICATION
Tills Appendix is to be completed only by (n) the Applicant, and (b) any legal, cnflfy which has a direct p.n;jjprsjyin/Iptcrcs.t in the App)iic¥nt;Cxc^$ttig{7.$ pc.cccnt^na-.''0.tyh'fctf$).-It lfnbEto.be cdmplctcd^by, nny legal entity which lias'.o.nly au/lndirect ownership interest-in the -Applicant.
Pursuqnt to Municipal Code Section 2-154-010, is the Applicant or any 0\\mcr idcntjfied as,a building'code scof$aw-bY.pfdb'Icm landlof&ffrrsuaril to Section 2-92741(5 ofthc'Mumclphi Code?
[ ]Ycs r>TNo
If the Applicant js a legal entity publicly traded on any exchange, .ts.any officer.qr director of
iHcApplic^ code scofflaw or problem .landlord pursuartt tq Section
2-924f 6 pTtlic Maiiidpil C^>dc?
[ ]Yes [ ]Np W] Not Applicable
IFiyes:tp:(l^ pej^pri or legal-entity
idqrtt.fe orproGiyrMlandldril .iari'd the'address of-the building or
buildings to whlch JhCiP^
JTLIJuN'G OUT THIS APPENDIX B GONSMf UTOS ACKNOWLEDGMENT! AND AGREEMENT THA^f jTHIS APPlNDD^$ IS Ir^e^IpORATteD B Y
AND THAT THE J^PRESENT^ THTS^E^^ Sj^jE^
PERJTj&Y ON PAGE li'OF TfJE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for.you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This reccrtificatioivis bcing:subtmttcd in. connection with 3911-3985'N MltvvwkoW487i1-4^777 W Irving Park Road [ideatiSy the Matter]. Undchpeh^
lie/she is authorized (d-cxjfcut&'titis ED/S recertification on behalf of the Disclosing Party, (2) wamnils that aifccrtificutidns^aiid statements contairied.m the Disclosing Party's original EDS are true,-accurate and complete as-.of'thc,datc furnished to' the City aiid continue 'to. be. true, accuratelah'd '^^plete%.^u>e.iliatcoftliis° rccertification, and (3) reaffirms its acknowledgments.
E. Thomas Collins, Jr. Irrevocable Children's Trust . »
dated 04/10/98 on behalf'.of kimberly Anne Datc; Q2JISU J'/(>
(Print or type legal name of Disclosing Party)
(sign Irfro)
Print or type name of signatory:
Ponry Welnstcln .
Tide of signatory:
-Trustee . _
SjftntSl'd and sworn to before me bri'[elate) .'^.-i? £•« | [j > by
C-dQX^ G6unt>'> I"!— . Estate].
Q^^A. ^i^Q. ; Notary Public.
Commission expires: • / *¦/ .« /*"}• .
Vcr. n-oi-os
WefAj[? ANEL MEDINA
CI TY 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: Collins Family Limited Partnership
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] the Applicant OR
2- f/1 a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Parly holds an interest: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (sec 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: 980 North Michigan, Suite-4280
Chicago, IL 60611
Telephone: (312)377-9111 Fax: Email: JcolHns@clarkstreet.com
Name of contact person: John Collins ^_
Federal Employer Identification No. (if you have one): ______ „ . .
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") lo which this EDS pertains. (Include project number and location of property, if applicable):
Zoing Amendment for properly located at 3911-3985 Nodh Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS? DPD ^
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification U and Contract #
Page 1 of 13
SECTION" II - DISCLOSURE OK O WMiUSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Limited liability company Limited liability partnership Joint venture
Not- fo r- pro fit corpo ratio n
(Is the not-for-profit corporation also a 501(c)(3))?
[]Ycs . []No
1. Indicate the nature of the Disclosing Party: Person
| ~| Other (please specify)
Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership Trust
For legal entities, the state (or foreign country) of incorporation or organization, if applicable: Illinois
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 f/]N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below the full names and titles of all executive officers and all directors of thecntity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there arc no such members, write "no members." For trusts, estates of 6'tn.er 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 ou its own behalf.
Name
E. Thomas Collins, Jr.
Title
General Partner
Sylvia Doyne Collins
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 inicrcst in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in n 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 npplicam which is reasonably intended to achieve full disclosure.
Name Business Address Percentage interest in the
Disclosing Party
Please see Exhibit 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 {/[No
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 tlie 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 cither ask the City whether disclosure is required or make the disclosure.
Page 3 of 1.3
Name (indicate whether Business Relationship to Disclosing Parly Fees (indicate whether
retained or anticipated Addicss (subcontractor, attorney, paid or estimated.) NO'FLi:
to be retained) lobbyist, etc.) "hourly rate" or "l.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
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 Partybcen declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes Df 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?
[JYes []No
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 1 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
Page A of 13
2. The Disclosing Parly and. if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 1I.B.1. of this EDS.
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, 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;
arc 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;
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
c. 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 stale 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 Parly, 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 DiseluMiig 1'auy, no: any Coniracloi, nor any Affiliated Hiilily of either tlie Disclosing Party 01 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:
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;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
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 orpartners, 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 list6
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.
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.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Parly must explain below:
N/A
Page 6 of 13
If the leuers "NA," the word "None," or no response appears on the lines above, il will be conclusively presumed that the Disclosing Paity certified to the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").' N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Parly (check one)
[ ] is (/] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc 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):
Page 7 of 13
If the letters "NA." the word "None,'' or no response appcais 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 arc defined in Chapter 2-156 of the M unicipal Code have the same meanings when used in this Part D.
In accordance with Section 2-1 56-110 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 ¦ f/|No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for tax.es 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 docs not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Property Sale?
[]Ycs \/\ No
If you checked "Yes" to Item D.l., 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 cither 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
Page 8 of 13
comply wiili these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
^ 1. The Disclosing Parly 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 front 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 Parly verifies that, as a result of conducting the search in step I above, the
Disclosing Parly has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that Ihc following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: 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 arc 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):
(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.
Page 9 of 13
The Disclosing. Party will submit an updated certification at the end of each, calendar quarter m which there occurs any event that materially affects the accuracy of the statements and infoi minion set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that cither: (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.
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 L]No If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (Sec 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION Vll - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Parly understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become purl 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 arc 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.
D. 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.cilvofchicago.orp/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
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.
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.
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:
Pane 11 of 13
I-M . The Disclosing Fatty is not delinquent in the payment of any tax administered by ilic Illinois Ocpaitmciu of Revenue, nor are the Disclosing Parly or its Affiliated Untitles delinquent in paying any fine, fee, lax or other charge owed to the City. This includes, hut is not limited to, nil 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 v/ill not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Panics List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Parly 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 v/ill not, without the prior written consent of die City, use any such contractor/subcontractor that docs not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide tnilhful certifications.
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 tnic, accurate and complete as of the date furnished to the City.
Collins Family Limited Partnership (Print or type natat^of Disclosing Party)
(Print or type name of person signing)
Genaral Partner
(Print or type title of person signing)
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to he completed only by (a) the Applicant, and (b) any legal entity nhich has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to he completed by any legal entity which lias 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 IT.B.1 .a., if the Disclosing Party is a corporation; all partners of tlie 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 tlie 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 (I) the name and title of such person, (2) the name of (he 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
EXHIBIT A
COLLINS FAMILY LIMITED PARTNERSHIP
E. Thomas Collins, Jr. %
Sylvia Doync Collins / ~J%
John Collins j \%
Perry Weinstein, as Trustee of the E. Thomas Collins, Jr. Irrevocable Children's Trust Oated 04/10/96, for the benefit of.
; Limited Partner ¦ :%
i *
Perry Weinstein, as Trustee of the E. Thomas Collins, Jr. Irrevocable Children's Trust Dated 04/10/96, for the benefit of.'
, Limited Partner ! / ,%
Perry Weinstein, as Trustee of the E. Thomas Collins, Jr. Irrevocable Children's Trust . Dated 04/10/96, for the benefit of
; Limited Partner , Ya
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX 13
BUILDING CODE SCOFFLAYY/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (n) the Applicant, and (1)) any legnl entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an Indirect ownership Interest in the Applicant.
I. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identifted as a building code scofflaw o'r'problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
tXTNo
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Ycs
3. If yes to (I) or (2) above, please identify below (he name of the person or legal entity
Identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply,
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDED B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you lo recertify your EDS prior lo submission to City Council or on the dale of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
.This rccertification is being suhmittcd in connection with 3911-3985 M Milwaukoo/487,H777 W Irving Park Road [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date furnished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.
Print or type name of signatory:
" John E Collins
Title of signatory: General Partner
,,by
Signed and sworn to before mc on [date] O.
^TbVm C/aljUyy^ , at. Cexsp County, X7~
Notary Public.
Commission expires:
OFFICIAL SEAL AN EL MEDINA NOTARY PUBLIC, STATE Of ILLINOIS MyConimls$lonnxn!rosAprilu 2017
CITY OF CHICAGO I0CO NO M1C DISC L OS UK E S T A T K ME NT AND AFFIDAVIT
SECTION 1 - OENEttAI. 1NFOUMAT10N
Legal name of the Disclosing Parly submitting this EDS. Include d/b/a/ if applicable: JEC Investments, LLC
Check ONE of the following (luce boxes:
Indicate whether the Disclosing Parly submitting this EDS is:
1. [ ] the Applicant
OR
2. a legal entity holding a direct or indirect interest in the Applicant. Stale the legal name of the
Applicant in which the Disclosing Parly holds an interest: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (see Section 11.13.1.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
Business address or the Disclosing Party: 980 North Michigan, Suite 1280
Chicago, IL 60611
Telephone: (?l?).3_TZl9_1.ll Fax: , Email: Jcplllns@clarkstreet.com
Name of contact person: John Collins .
Federal Employer Identification No. (if you have one): • . •' .
Brief description of contract, transactions other undertaking"(referred to below as the "Matter") to which this EDS pertains. (Include project number and location" of property, if applicable):
Zoning Amendment for property locatod at 3911-3985 North Milwaukee Avenue; 4671-4777 West Irving Park Road
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 ft _ and Contract It
Page 1 of 13
SECTION I) DISCLOSURE OK OWNERSHIP INTERESTS
A NATURE 01" THE DISCLOSING PARTY
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
I] Yes ¦ []No
I. Indicate the nature of the Disclosing Party Person
Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership Trust
| | Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable Illinois
3. For legal entities nonorganized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[ ] Yes I ] No . f/1 N/A
13. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names anditiclcs 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 oi"other similar entities, listIf the entity is a general partnership, limited partnership, limited liability.company, lirnitcd,liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entitythatcontrols 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
John E. Collins Manager and 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,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of n trust, estate or other similar entity. If none, state "None." NOTE: Pursuant lo 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 Parly
John E. Collins 980 N. Michigan, #1280, Chicago, IL 60611 100% "
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-1.56 of the Municipal Code, with any City elected official in the 12 months before the dale this EDS is signed?
[]Ycs (/(No
If yes, please identify below the namc(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 arc 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.
Page 3 of 13
Name (indicate whether Business Relationsliip to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTH:
to be retained) lobbyist, etc.) "hourly rate"" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
y\ Chech here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities SECTION V -- CERTIFICATIONS
-
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under 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 [ ] 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
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") arid' legal requirements), if the Disclosing Party submitting this:EDS is the Applicant-anci is doing'busifiess wtfh 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 ihc 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
Page 4 of 13
The Disclosing Party and, if the Disclosing Party is a legal entity, all of ihose persons or entities identified in Section 11.0.1. of this EDS:
n. arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, stale or local unit of government;
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;
are not presently indicted for, or criminally or civilly charged by, a governmental.entity (federal, stale or local) with committing any of the offenses set forth in clause 13.2.b. of this Section V:
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, stale or local) terminated for cause or default; and , •
c. 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.
The certifications in subparts 3, 4 and 5 concern:
the Disclosing Party;
4 any "Contract6f""(iheahihg any 'contractor Or subcontractor used by thc?« > ¦•: •! • '
any "Affiliated'Eritity" (meanings person or.entity that, directly or indireotIy:{controls:the -; Disclosing Party, is controlled by the Disclosing Party, or is, with tlie Disclosing Party, under - ¦¦ common control of another person or entity. Indicia of control include, without limitation: interlocking.Tnanagcment or.'owhership; identity of interests among .family membefsi'shared facilities and cquipmcritpcommon use of employees; or organization of a business entity.'following;the T 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 Disclosiug 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 Conn actor, nor any Affiliated En lily of cither the Disclosmg Parly or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Coniractor, 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 01 engagement in connection with the Matter:
bribed or attempted 10 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;
agreed or colluded with other bidders or prospective.bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an.admission of such conduct described in.a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or . •
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither-the Disclosing Party, Affiliated Entity ^or'Gontractor,se.bf,any*state-orof!ith6;Unitc.d--States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither-thc'Disclosing Party nor any AffiliatedfEottty is listed on any.p'f ihctfollpwing lists maihtairied-pyrthb Office of Foreign Assets C^ntroLofcthe^ the Bureau of.Industry and Security of the UyS. "Depart Specially Designated Nationals List, .the Denied Persons List;ffie.Unyerifi^
Debarred-IsistC.: . ; ..... >n ^!:/;;,^-'i.f; _i.«;>.-.->j.-s.-j:, :••
6. ¦ »The Disclosing Party understands2-55 (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 .;. .
Page 6 of 13
11" the letters "NA." ihc word "None," or no response appears on the lines above, it will be conclusively p:e.-,umcd that the Disclosing Parly certified to the above statements.
S. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all cut rent employees of the Disclosing Parly who were, at any time during the 12-moulh period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, a1 any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is f/1 is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institutioh, then die 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 thispledge 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):
Page 7 of 13
If the letters "NA," the word "None," or no response appears on the lines above, ii 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.
In accordance with Section 2-156-110 of the Municipal Code: Docs 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 che;Matter?
[]Yes (/I No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3 if you checked "No" to
Item D.l., proceed to Part E. , ,
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property 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,p,ursuant;tq the Cityjs eminent domain power does not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Property Sale?
[ •] Yes (/J No
If you checked "Yes" to hem D.l., provide the names and business addresses of the City officials or employees havjng.s.uch,interest and identify the nature of.1such 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 cither 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
Page 8 of 13
comply wnii ihese disclosure requirements may make any conuact entered into with the City in connection with the Matter voidable by the City.
"/ I. The Disclosine. Party verifies that the. Disclosing Party has searched any and all rccoids of Ihc 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 Ihc Disclosing Parly 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:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VIE For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federaPLobbying Disclosure Act of .1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary): ;
(If no explanation appears or begins on the lines above, or if the letters "N&." 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 lo influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee 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.
Page 9 of 13
The Disclosing Pany will subniil. an tipdaicd certification a I the cud of each calendar quarter in which there occui s any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Re venue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing" Party must obtain certifications equal in form and substance to paragraphs A. P. through A ,4V above'from all subcontractors before it awards any subcontract and the Disclosing~:Party must maintain all such subcontractors' certifications for the duration of the M atter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally-funded, federal regulationsIs the Disclosing Party the Applicant? , .
[]Ycs []No If "Yes," answer the three questions below;
Have you developed and do you have on file affifmaUve.action programsipursuanL^to.applicabie federal regulations? (Sec 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Progranis, or the 'Equal Employment Opportunity Commission all reports due under the applicable filing requirements? '' . i
[] Yes [] No ' ": ' . '
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
t ] Yes [ ] No
If you checked "No" lo question 1. or 2. above, please provide an explanation:
Page I Oof 13
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COM PLIANCE, P EN A LTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
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 arc 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.
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.cityofchicaijo.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. Thc'Disclosing Party must comply fully with the applicable ordinances.
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 submiitcd may be rescinded or be'void or
voidable, arid 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. , ... : ...
It is the City's policy to make this document available to the public on itsTntemct-site arid/or'up on
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, pr
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 fclcase,ofmfonnation
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 tlie 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:Lof
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:
Page 11 of 13
F.l. 'Flic Disclosing Parly is not delinquent in the payment of nny tax administered by the Illinois Department of Revenue, nor arc the Disclosing Party or its Affiliated F.ntitics delinquent in paying any line, 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, properly taxes or sales taxes.
F.2. If the Disclosing Parly 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 Serviccs Administration.
F.3 If the Disclosing Party is Ihc 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 docs not provide such certifications or that the Disclosing Parly has reason lo believe has not provided or cannot provide truthful certifications.
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
JEC'Investments, LLC
Jojjiq^-ggiyrjs'.-^ ¦;
¦(Pfinror'fyp'c1'-name"of person signing)
Manager and sole member
(Print or type title of person signing)
AN EI MEDINA OFFIClAt SE-Al
Noioiy Public. Sloio ol Illinois My Commission Expires April .14. 2017
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is lo be completed only by (a) 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 cterk, 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 ILB. 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, cliicf financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?"
I ] Yes f/] No
If yes, please identify below (I) 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 01'' CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX B
BUILDING CODE SCOFFLAVY/PROBLEM LANDLORD CERTIFICATION
Tins Appendix is to be completed only by (n) the Applicant, and (b) any legal entity which has a direct ownership Interest in flic Applicant exceeding 7.5 pcrcciiC(nn "Owner"). It Is not to be completed by nny legal entity which has only an Indirect ownership interest in the Applicant.
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any.Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Ycs t>tfNo
If the Applicant is a legnl entity publicly traded, on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-^116 of the Municipal Code?
[ ]Ycs [ ]No -fV] Not Applicable
If yes to (1) or (2) above; please identify bejow the name of the person or legal entity identified as a building code scofflaw or problem landlord-ahd the address of the building or buildings to which the pertineril code violationsi apply.
.FILLING OUT THIS APPENDDX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART-OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPEI^DIX B ARE SUBJECT TO THE CERTD7ICATION MADEUNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission lo City Council or on the date of closing. If unable, to recertify tnjthfully, the Disclosing Party must complete a new EDS will) correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3905 N Milwaukeo/4 871-4777 W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that
he/she is authorized to execute this EDS rccertification on behalf of the Disclosing Parry, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
arc true, accurate and complete as of die date furnished to the City and continue to be true,
accurate and complete as of the date of this recertification, and (3) reaffirms its
acknowledgments.
JEC Investments, LLC
(Print or type legal name of Disclosing Parly)
John E. Collins
Title of signatory:
Manager-end Sole Member
Signed and-sworn-to before mc on [date] 2 . I g » } U by
-^h\\*\ f/lp-Uyyy,Ca—. Aj£jDajZ. County, .Yr L
Commission expires:
OFFICIAL SEAL
ANEL MEDINA NOTARY PUBLIC, STATE OF ILLINOIS My Commission Expires April 14,2017
<5 •*mrVvvvvl_vwyr
CITY OF CHICAGO ECONOMlC: DISO,OSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name oftlic Disclosing Party submitting this EDS. Include d/b/a/ if applicable: E. Thomas ColWis, Jr Irrovocatlo Children's Trus; doled CK/10/96 on behalf of j
Check ONE of (he following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
[y\ 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: CSD Six Cornors LLC
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 Parly holds a right of control:
B. Business address of the Disclosing Party: 900 North Michigan. Suite 1260
-Chicago, IL 60611 . '
Telephone: (312) 377-9111 Fax: ' Email: jcollins@clarkstreet.com
Name of cdntact person: John Collins ¦¦
Federal Employer Identification'No. (if you have one): \ ^ ' •
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):
Zoning Amendment for property located at 3911-3985 North Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS7 DPD
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract # ,
Page 1 of 13
SlCCTfON U - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURF OF THE DISCLOSING PARTY
Limited liability company Limited, liability partnership Joint venture
Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes [ ] No
I. Indicate the nature of tlie Disclosing Pitrly Person
Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership Trust
| j Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable: N/A
3. For legal entities not.organizcd'in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[]Ycs []No .[/I 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 arc legal entities. If there are no such members, write "no members." For trusts, cstatcs'br other similar entities, list below the legal titlcholdcr(s).
If the entity is a general partncrshipi limited partnership, limited-liability company,\limited.liabi.lity
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or.any other person or,entity;thatrcppjLrplslth of the DisctosingiParty.
NOTE: Each legal entity listed belowName-Perry Weinstein
Title Trustee
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,
Page 2 of 13
Name
interest of a nicmbei or manager in limited liability company, or interest of a beneficiary of a trust, estate or other similar entity- If none, state "None." NOTE: Pursuant to Section 2-1 5-1-030 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.
Business Address Percentage Interest in the
Disclosing Party iCollins 980 N Michigan Avenue, #1280, Chicago IL 60511
SECTION HI -- 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?
[]Ycs f/No-
If yes, please identify below the name(s) of such City elected official(s) and describe such rclationship(s):
SECTION IV - DISCLOSUR1E.pEiSUBCONTRACTORS AND OTHJLRRETAINED1,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 .uot 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 adminisirativc. 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 pcrspn;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 cither ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name, (indicate whether Business Relationship to Disclosing Parly Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly laic" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
y\ Check here if the Disclosing Parly 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 [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If ''YesV,:has;-the persdn:critcrcd:into a'court-approved paymcht-of all support owed and
is the person in compliance with that agreement?
[fYes " [pNo ' ':'• ¦ •
D. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article l")(which the Applicant should consult for defined terms (e.g., "doing'busincss");arrd lc'gal fequircThents), if the Disclosing Party submitting this EDS is" the Applicant and is doing business with the City, then the Disclosing Parly certifies asTollows: (i) neither the Applicant nbr'any'controlling p'ersoti 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 1 applies lo the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
? The Disclosing Party and, if ihc Disclosing Parly is a legal entity, all of those persons or entities identified in Section ll.B.l. of this HDS:
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding Ihc 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 pcrformingare 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;
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
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 die Disclosing*Partyin«v
connection with the Matter, including but hot limited to allpersons or legal entities disclosed under
Section IV, "Disclosure.of Subcontractors.andiOther-Retained Parties"); j ' . . ¦>
any "Affiliated Entity?;(meaning a person pr 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 pwnefshipjddentity.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 tlie 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 Untiiy of cither the Disclosing Parly or any Contractor nor any Agents have, during the five years before the daic 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:
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 Ihc federal government or of any slate or local government in the United Stales of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party lo any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a- or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
A. Ncitherthc Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or.partners, is barred from contracting with any unit'bf 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.
Neithc'rHhc^Disclosiii^ •Party nor'any Affiliated Entity is listed on :any o f the 'fo llowing l ists
maintained%;the'Offi^^ Control of thc'U.S.-'D.cpartm or'the
Bureau of Industry and Security of the-'U.S. Department of Commerce or their successors': the Specially
Designated (Natiohals 'List.'ithe^b'ehied-Person's List; the Unverified LisC-the¦Entity^isf:an'3H'he
DebarrcdjL:ist: ¦¦¦ > ¦ • - • • • v . ...v. ... . ,<;.> ......
The Disclosing Partyxinderstands and shall comply with'thc applicable requirements of Chapters
2-55 (Legisla.tivcTnsp'cctor!5enefa'l)r2-56 (Inspector Gencral) aridl2-'l56 (Governmental £thics) of the
Municipal Code. ¦ ¦ -
If the Disclosing-Parfy is unable to certify to any of the above statements in this Part B (Further Ccrtificatiofis);:the Disclosing Party must explain below:
N/A
Page 6 of 13
If ihc letters "NA," the word "None." onto iespouse appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To (he best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any lime during the 12-nionth period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge afier reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is (/] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the-Disclo'sirig Party pledges:
"Wc arc not and will not become a predatory lender as defined iivOha'ptcr 2-32 of die 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. Wc 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 lendcrwithin the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
Page 7 of 13
Irihc loners "NA," the word "None," or no response appears on illc lines above, it will be conclusively presumed that the Disclosing Party certified to tlie above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-1 56 of the Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 of the Municipal Code: Docs 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. 1, proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in tlie 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 tlie City (collectively, "City Property Sale"). Compensation,fqr.propcrty taken pursuant to the City's eminent domain power docs not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Property Sale?
[]Ycs I/lNo • '
If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employee^ haying suc^jnjergs.t and identify &e 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
Page 8 of 13
comply' wivh these disclosure rccpiiremenis may make any contract entered into with the City in connection with the Matter voidable by the City.
1. The Disclosing Party verifies that Ihc Disclosing Party has searched any and all records of
ihc 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 Parly verifies that, as a result of conducting the search in step I above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City arc 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'tlie Matter: (Add sheets if necessary):
(If no explanation appears of 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.atlcmpt 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.
Page 9 of 13
The. Disclosing Parly 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.
The Disclosing Party certifies that cither: (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".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.I. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is fcderally funded, federal regulations,require thc,A.pplicant and a|l,proposed . ,
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant? ..
[]Ycs []No ...
If "Yes," answer the three questions below:
Have you developed and do you have on file affirrhatiye action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[]Ycs []No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs^ o'r^fc^EquaI%mplo'ymc'nt.Opportunity Commission all reports due under tlie applicable filbg-rcqu^reitfejitS? '•
[] Yds'' ['] NO"
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[] Yes' [ ] No '
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page. 10 of 13
SECTION VII - ACKNOWLEDGMENTS, CON TRACT INCORPORATION, COM PLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
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 arc 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.
The City's GovcrnmcntalEthics and Campaign Financing Ordinances, Chapters 2-1 56 and 2-1 64 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or trans'a'ctiohs. The full text of these ordinances and a training.program is available on line at www.cityofchicrigo".org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL.60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
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 uridcrfhc contract or agreement (if notVcsfcindcd or '< void), at law, or in equity,¦including terminating the Disclosing Party's participation'ih^tlielMatter.ajid/or declining to allow theDisclosirig 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.
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-tliis :EpS;rnay be made available to the public on the Internet, in response to a Freedom of Information Actirequest, 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.inf^'mafipn contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes', the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. 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 J -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 2rl 54-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, noi arc 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. Ifthc 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'contxactor/subcoritractor that docs not provide such certifications or that thci Disclosing'Party lias reason to believe has not provided or cannot provide truthful certifications.
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
Unforpcnalty^o^^ below:.(1) warrantstthat he/she is authorized to execute
tiiis'-EDS warrants that all
periifipajioaV^ and Appendix.^ (if applicable) arc true/accurate
and complete as.of'ihe .date fofnisiicd to the City.
LIMnCAn *. bmxaUa CUAjift Tumi tint WlCWai Wmtt(Print or twit name. Of Disclosing Party)
T^ign^ercJ Perry^Welnstein
(Prij&or,typ^ .
Trustee
(Print or type title of person signing)
Signed wid.s^orii'.to^-beforeme OiL(dato) /vdV-' '°/ at . />yd^^¦v^Cdutffew . ,.A: t-> (state).
^^^^^
Commission expires:
;NADA POPOVIC t
-WOTARV PUO.LIC, STATE OF JLl JN'OIS ¦ Vvv^&S^^s 07/00/2017
Page 12 of 13
CITY 0I: CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appcudix 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 Parly" 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 dale this EDS is signed, the Disclosing Party or any "Applicable Part)'" 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 ELB.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 die 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 tlie 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 APPENDIX B
BUILDING CODE SCOFFLAWPROBLEM LANDLORD CERTIFICATION
This Appendix is (o be completed only by (u) (lie Applicant, and (b) any legal entity which has u diced ownership interest in the Applicnul exceeding 7.S percent (an "Owner"). It Is not to be completed by any legal entitywhich has only au indirect ownership interest in the Applicant.
1. Pursuentto Municipal Code Section 2-154-010, is the Applicant or any Owner identified as building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes
[ ]No
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a bui lding bode scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Ycs
3. If ycs'-lp (1) or (2) above; please identify below the name of the person or legal entity identified as h building 'codescofflaworproblcrh landlord and the address of the building or buildings to whichliie;pcrtinent,codc violations apply,
JHLLING OUT THIS APPENDIX P. CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX Q IS INCORPORATED BY INFERENCE INTO, AND MADE A PART-OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The puipose of ihis page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected infonnation)
RECERTIFICATION Generally, for use with City Council matters. Not for City procurements unless requested.
This recertification is being submitted in connection with 3911-3985 N MilwaukeeM871-4777 W Irving Park Road
[identify the Matter], Under penalty of perjury, the person .'signing below: (1) warrants that
he/she is authorized to execute this EDS rccertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as of the date furnished to the City and continue to be true,
accurate and complete us of the date of this rccertification, and (3) reaffirms its
acknowledgments.
E. Thomas Collins, Jr. Irrevocable Chlldren'3 Trust
datod 04/10/96 on behalf of Cariy Elizabeth Date- @(Print or type legal name of Disclosing Party)
(sign hero)/
Print or type name of signatory:
Perry Weinstein
Tide of signatory.
Trustee
Signed and sworn to before mc on [dale] J?/\ (f , by
ptjrr-u^lQe.in*!*'* ,« Qnorr^ County,_I£Z_^ (state].
r
UjV* ClJ/cJ'** NotafyPubHc-
Commission expires: ^ • / Lj . j
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OFFICIAL SEAL
' NOTARY PUBLIC, STATE OF ILLINOIS
vcr. U4U-85 < My Comhilsslon Expires April 14.2017 1
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of (he Disclosing Parly submitting this EDS. Include d/b/a/ if applicable: Clark Street Development LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ) the Applicant
OR
\/\ 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: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (sec Section Il.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: 980 North Michigan, Suits 1280
Chicago, IL 60611
Telephone: (312) 377-9111 Fax: Email: jcollins@clarkstreet.com
Name of contact person: -John Collins
Federal Employer Identification No. (if you have one):
Brief description of contract,vtransactibn or other undertaking (referred to below" as the "Matter") to which this EDS pertains. (Indlude project number and location of properly, if applicable):
Zoning Amendment for property located at 3911-3985 North Milwaukee Avonuo; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS? D' D
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification it ^ and Contract //
Page I of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
y/J Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes [ ] No
j ] 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 Slate of Illinois as a foreign entity?
[]Yes I] No (/N/A
B. IF THE DISCLOSING PARTY IS A LEG A L ENTITY :
I. 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 titleholdcr(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the namc and title of each general partner, managing member, manager,pr any other person or entity .that .controls the day-to-day management of the Disclosing Party. N6TE: Each legal, entity listed bc.lpw.must submit an EDS on its'owri behalf.
Name
E. Thomas Collins, Jr.
Title Mnnagor
Richard E. Hulina
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,
Page 2 of 13
interest of;; member or manager m a limited liability company, cm" interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."' NOTE: Pursuant to Section 2-1 54-030 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 lull disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
Please see attached Exhibit 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 .[/j No .
If yes, please identify below-the.namc(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 pr .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 cither ask the City whether disclosure is required or make the disclosure.
Page 3 of .13
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 rale" or "l.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 eniiiics. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners ofbusincss entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who dircctly'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 [/I No [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If'"Yes,"'has thb'pcrsQii ehtcrcd'irito a court-approved agrcemcht for payment of all support owed and is the person in compliance with that agreement? .
H Yes ¦ 1 []'No '
FURTHER'CERTiFIC'ATIONS " r i-.
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult fo^ and legal requircmehtsj,'if the^Disclosihg'Party
suDniittingmi.s ElJS is the Applibarifahd is doing business with tlie'City, Ihen'the'DiscIdsing'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, disHonestybr deceit against'aii 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.
Page 4 of 13
The Disclosing Parly anil if the Disclosing Parly is a legal entity, all of those persons or entities identified m Section M.B.I, of this EDS:
a arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, 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, slate or local) transaction or contract under a public transaction; a violation of federal or stale antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making, false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, stale or local) terminated for cause or default; and
c. 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.
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, antong family members, shared facilities and equipment; common use of cmplpyecs^pr 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 ol" either the Disclosing Parly or any Contractor nor any Agents have, during the live years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated F.iuity of a Contractor during the five years before the date of such Contractors or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or tiny 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;
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; of
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
violated mciprbvisiohs of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither tiic^isclosiifig'Party/Affiliated Entity or Contractor, or any of their'cmployccs; officials, agents or partners, is barred from contracting with any unit of state or local governirient 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 bf any state or of the"Unit&PStates Of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the ^'KcibVirfgJP,arlty-n8f afiy Affiliated Entity is listed oh any' of^^bjl^ih^lists
maintained'by this Office $$&%ig&£s$et&;Cdntj?bl' 6f the U.S. Department ofHotc^rei'S'ttry'of'tfec - '
Bureau of Industry and Sccurity 'bf th'c:tj;S. Department of Commerce Or tlieif successors: the Specially
Dcsignated'Natib'ffaisTli'st:- tho''DMeThleii'P'ersbns^List;- the'Unverified List, the EntityC'istiarid'the'
Debarred List. ; '. ¦ ••
Thc^D'isclbsli^^ and shall comply with the applicablc•r^uiifenicnt8'>'0i''f Chapters
2-55 (Legislative Ins^ General) and 2-156 (GovenifneritarEthic's) of the
Municipal Code. "¦' ' • ¦
1. If the Disclosing Party isTunable to-ccrtify to any of the above statements in'this Part B (Further Certifications), the Disclosing Party must cxplain'bclow:
N/A • . '
Page 6 of 13
If the letters "NA," the v/ord "None." or no response appears on the lines above-, ii will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Party's knowledge, after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS. an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none") As to any gift listed below, please also list the name of the City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is (/] is not
a "financial institution" as.dcfincd in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party'pledges:
"Wc are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. Wc 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. Wc 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):
Page 7 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed thai 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.
In accordance with Section 2-156-110 of the Municipal Code: Docs 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 L/No .
NOTE;, If you checked "Yes" to Item D.I., proceed to Items D.2. and D.3. If you checked "No" to ItcmD.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property 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"). Compensatipn for.property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Property Sale?
[ ] Yes . f/1 No
If you checked "Yes" to Item D.l., 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 cither 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Parly must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
1. The Disclosing Party verifies that the Disclosing Parly 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 Ihc search in step I above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Parly verifies that ihc following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI « CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: 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):
(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 die 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.
Page 9 of 13
The Disclosing Parly 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.
The Disclosing Party certifies that cither: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) il 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".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to':paragraplis A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certification's for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is fedcraUy^funded, federal regulations require.^^thc. Applicanta^d all proposed subcontractors to submit the fallowing information with their bids or in writing'at the outset of negotiations. ...
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No
If "Yes," answer;thcvthxce questions below:
1. ' Have you developed and do you have on file affirrriativc action prbgrams pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[]Yes []No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Conifacl\C^ Programs, or the Equal Empioynii$'nt'Op^oituiuty'Commiss'jon ail reports due
undcr4Ke7appiicab'l6 flli'h'g:'rcqu'ircments? 1 '
[]Yesv '• ''';" [J-No ' "';•¦>¦¦¦
Have you participated in any previous contracts or subcbritfacts subject lb the equal opportunity clause?
UYcs' " [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII - ACKNOWLElXiMENTS, CONTRACT 'INCORPORATION, COMPLlANCE, PENALTIES, D1SCLOSUKE
The Disclosing Parly understands and agrees that;
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 lo 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.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2M64 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.orR/Ethics . and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contractor 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 riot 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.
It is the City's policy to make this document available to the public oh-its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments torthis EDSjrnay 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;p,qssible
rights or claims which it may have against the City in connection with the public rcTea's'eidf information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS. ' ¦
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Tarty 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, die 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 thai:
Page 11 of 13
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 lo, 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, norpeiniit 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 afili substance to those in F.i. and F.2. above and will not, without'tlic"prior'Written, consent of the City, use any such contractor/subcontractor that docs not provide sucK-ccrtificatidns of that the 'Discldsing'Party!has reason to believe has not provided or cannot provide truthfufecrtifications.
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 mbst-be attached to this EDS.
CERTIFICATION
Und6r;p^ below: (1) warrants that he/she is;authorized.to execute
this'ED„S 'anil Appendix A .(if applicable) on behalf of the Disclosing Party, arid (2) warrants'that'all .certifications'and statements contained in this EDS and Appendix A (if applicable)'are true, accurate and cpmplete as of the date Furnished to the City.
-Glark'StrBetDeyelqprnen
(Prmtb^^ Anrtp pf pisclo^ng Party)
Manager:' ":."'.:':' '¦ r ;' ¦ ¦ ¦ • (Print er type title of person signing)
Signed and sworn to before nitron (date) Q \ 1 f~>) I ^
at ¦Q&fi£.L'-' County,' < -' (state).'
fefed'A ¦ Q'$&™ -Notary Public.
Commission'expires: f^SM 1 I <-{ )-l-*"} •
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
AIT'ENDIX A
FAMILIAL RELATIONS HITS WITH ELECTED CJTV OFFICIALS AND DEPARTMENT HEADS
Tliis Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which lias 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, tlie 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 (I) all executive officers of the Disclosing Party listed in Section U.B.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 Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [/] No
If yes, please identify below (I) 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
EXHIBIT A CLARK STREET DEVELOPMENT LLC
l-lulina Family.Limited Partnership ¦%
Collins Family Limited Partnership ', ':%
Peter Eisenberg i .%
Andy Stein \ i%
James Kurtzweil \%
Fritz DudaJr, %
John Collins ,%
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX B
BUILDING CODE SCOFFLAVY/PROHLEM LANDLORD CERTIFICATION
Tills Appendix is (o be completed only by (n) (he Applicant, and (b) any legnl entity which has a direct ownership Interest in the Applicant cxcccdlug.7.5.pcrcciit (an "Owner"). It is not to be completed by any legal entity which has only au Indirect ownership Interest in the Applicant.
Pursuant to Municipal Code Section 2-154r0I0, is the Applicant or any, Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthc Municipal Code?
[ )Ycs tMNo
-If the Applicant is n legal cntiiypublicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthc Municipal Code?
[ ]Ycs [ ]No -^A Not Applicable
3. If yes.to (I) or (2) above, please identify below (he nahic oftlic person or legal entity" idchtificd as a building code scofflaw or problem landlord and the address of the building or buildings to which tiie pcrtinentpCodc violations apply,
JKLLING OTJTTfflS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AJND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY Rii^l^d^iDNTO, AND MADE A PART OF1, THE ASSOeUTEb EDS, AND THAT THE REPRESEOTATiONS MADE IN TJnS/^E^^.'ARE .SUBiECTTO TB1D CERTtFICATTON MADE UNDER PENALTY OF PERjTJRY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior lo submission to Cily Council or on the dale of closing. If unable to recertify truthfully, ihc Disclosing Party must complete a new EDS with correct or corrected information)
UECERTIFI CATION Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3905 N Milwaukeo/4071-4777 w Irving Park Road
[identify Uic&ftttdr] Under, penalty' of perjury the pcrson'signing below :'t(i)^a'r/antsrfliat
he/she'is authorized to execute this EDS rccertification on behalf of the Disclosing1Party,"(2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
arc true, accurate and complete as of the date furnished to the City and continue to be true,
accurate and complete as of the dale of Ihis recertification, and (3) reaffirms its
acknowl edgmenls.
Clark Street Development LLC (Print or type legal name of Disclosing Party)
(sign-here)
Print or type name of signatory:
RIchard.Hulina,. . ,
Title of signatory:
Manager
Signcd;and swpfivt6 before me oh^date] - j&/r|.-t:n lk'ta».- fvj^iiby '7> ilil ^' ^,'(vrv,ai ¦ #^V*/' 'County.*-rp/L
Notary Public.
Commission expires:
OFFICIAL SEAL ANEL MEDINA NOT/WPUBUC.»P|lLLItWIS My commisslonExpires Aprl'. 1.4,20u
CITY OF CHICAGO ECONOMIC I) ISCLO.SU RE STAT EM ENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name ofthc Disclosing Patty submitting this EDS. Include d/b/a/ if applicable: The Hulina Family Limited Partnership
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
L/j a legal entity holding a direct or indirect interest in the Applicant. Stale the legal name of the
Applicant in which the Disclosing Party holds an interest: CSD Six Comers LLC
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) Stale the legal name ofthc entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 980 North Michigan, Suite 1280 .
Chicago, IL 60611
Telephone: (312)377-9111 Fax: Email: jcollins@clarkstroet.com
Name of contact person: John Collins
Federal Employer Identification No. (if you have one):
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):
Zoning Amendment for property located at 3911-3985 North Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS?_PJ_P_
If the Mailer is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification U and Contract #
Page 1 of 13
- DISCLOSURE OF OWNERSHl.r INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?
I] Yes []No ( | Other (pi case 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 Stale of Illinois as a foreign entity?
[]Ycs [INo [/IN/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 cntily. NOTE: For not-for-profit corporations, also list below all members, if any, which arc legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholdcr(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 thc Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Richard Hulina
Edward Hulina James Kurtzweil
Title Gonaral Partner
General Partner 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% ofthc Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager m a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None.'1 NOTE: Pursuant to Section 2-1 .vl-030 ofthc 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
Disclosine. Party
Edv/ard Hulina 980 N. Michigan, #1280 Chicago, IL 60611 j%
Holly Hulina Gange 980 N. Michigan, #-1280 Chicago, IL 60611 ] " %
Elizabeth Hulina Kurtzweil 980 N. Michigan. #1280 Chicago, IL 60611 ; %
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 |/J No
If yes, please identify below the name(s) of such City elected official(s) and describe such rclationship(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 arc 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 (he Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whet bet lousiness 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)
]fl 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 svho directly or indirectly owns 10% or more of the Disclosing Parly been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [/f 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
13. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article l")(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 Parly 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
The Disclosing Party and, if Die Disclosing Paily is,a legal entity, all of those persons or entities entificd in Section II.H.I . of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, 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;
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;
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
c. 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.
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 tinder 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 principal 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 dircctioti or authorization of a responsible official ofthc 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 cither the Disclosing Paity or any Contractor nor any Agents have, during the five years before the date litis EDS is signed, or, \vi;h respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before tlie date of such. Coniiaclor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthc City, the State of Illinois, or any agency ofthc federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
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.
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 tlie U.S. Department of die 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.
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.
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
Page 6 of 13
If the letters "NA," tin; word "None," or no i espouse appeal's on the lines above, it will be conclusively presumed that tlie Disclosing Party ccriified to the above statements.
8. To the best ofthc Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthc Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthc City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthc City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is (/] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"Wc arc 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. Wc 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 (he meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
Page 7 of 13
If the letters "NA," the word 'None," 01 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 arc defined in Chapter 2-156 ofthc Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-1 10 of the Municipal Code: Docs 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 t/] No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property 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.
Docs the Matter involve a City Property Sale?
[ ] Yes ¦ {/J No
If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify tlie 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 cither 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
Page 8 of 13
comply wit!) these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Patty 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 Patty 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:
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 ofthc 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):
(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 Pany 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.
Page 9 of 13
The Disclosing Pariy will submit .in updated certification at the end of each calendar quarter in winch ;hcrc occurs any event that materially affects the accuracy ofthc statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthc Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
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 lo the City upon request.
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:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" lo question I. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VIr -- ackno\vlei.k;ments, contract incorporation,
C0MPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Paviy understands and agrees that:
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 arc 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.
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.orR/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
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.
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 auth0ri7.es the City to verify the accuracy of any information submitted in this EDS.
The information provided in this KDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to ihc 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 ofthc 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 2-1 54-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
F.l. The Disclosing Parly is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Knlilies delinquent in paying uny fine, fee, tax. or other charge owed to the City. This includes, but is not limited lo, 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 lo use, any facility listed by tbe 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 Parly 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 ofthc 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.
NOTE: If the Disclosing Party cannot certify as to any of die items in F. 1., 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 date furnished to the City.
Hulina Family Limited Partnership (Printpjutype name ofDisclloS>ihg Party)
Richard Hulina
(Print or type name of person signing) General Partner
(Print or type title of person signing)
(state).
Signed and sworn to before me on (date) (Q I I Qg) |^
»< Pjfft&iH County, Xi
Notary Public.
I'ngc 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CI TY OFFICIALS AND DEPARTMENT HEADS
This Appendix is lo 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 lo 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 Parly 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 Parly or any "Applicable Parly" 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 (I) 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 genera! partners and limited partners ofthc Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthc 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.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] 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.
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AN!) AFFIDAVIT APPENDIX B
BUILDING CODE SCOFFLAWPROBLEM LANDLORD CERTIFICATION
This. Appendix is to be completed only by (n) the-Applicant, and fb) any legal entity which has a direct ownership interest in the Applicant cxcccdiug 7.5 percent (nn "Owner"). II Is not to be completed by any legal entity which has only an Indirect ownership Interest in the Applicant.
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthc Municipal Code?
[ ]Yes f>fNo
-If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416" ofthc Municipal Code?
[ ]Ycs [ ]No ^J] Not Applicable
If yes to (1) or (2) above; please identify below (he name of the person or legal cnlity identified as a building code scd'tfR.aw or problem landlord arid the address of the building or buildings to which tlte pertinent code vlofatlohs apply,
.FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PARTOF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPEND!* B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3985 N Milwaukee/4871-4777 W Irving Park Road
[identify die Matter]. Under penalty of perjury, the person signing below: (1) warrants that
he/she is authorized to execute this EDS rccertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in tlie Disclosing Party's original EDS
arc true, accurate and complete as of the dale furnished to the City and continue lo be true,
accurate and complete as ofthc date of this recertification, and (3) reaffirms its
acknowledgments.
The Hulina Family Limited Partnership (Print or type legal name of Disclosing Party)
By:
(sign here)
Print or type name of signatory: Richard Hulina
Title of signatory: General Partner
^-Signod and sworn to .before mc on [date] Q. [\ (_& 1 I I/, ¦foj^VvOjcd )4o\ < AQcat Cao tr. County,
\„ - 6 /f.o rl x VJ/^ Notary Public.
Commission expires: ^ ( {[ ("J
OFFICIAL SEAL-^ ANEL MEDINA fJOWm'.PUBUC. STATE 0F1LUN0IS J^m^O^OS April M. 2017
V ij mm n i
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I --GENERAL INFORMATION
A. Legal name ofthc Disclosing Party submitting this EDS. Include d/b/n/ if applicable: Flatiron Investment Company LLC
Check ONE of Hie following three boxes:
Indicate whether the Disclosing Party submitting this EDS is;
[ J the Applicant
OR
\f\ a legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthc
Applicant in which the Disclosing Party holds an interest: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name ofthc entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 980 North Michigan, Suite. 1280
' Chicago, ILO 60611
Telephone: (312)377-9111 Fax: Email: jcollins@clarkstreet.com
Name of contact person: Jonn Collins
Federal Employer Identification No. (if you have one): (.. ¦_¦ _
- ... ^ ...
Brief'description of contract, tfansactiorror other-undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Zoning Amondment for property located at 3911-3985 North MilwaukeeAvanue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS?____
If ihc Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract ii
Page 1 of 13
.SEC TION II - DISCLOSURE OF OWNERSHIP INTERESTS
A MATURE OF THH DISCLOSING PARTY
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))? []Ycs []No
1. Indicate the nature of the Disclosing Pat tys Person
Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership 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?
[]Ycs No [/j N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below the full names and titles of all executive officers and all directors ofthc entity.
NOTE: For not-for-profit corporations, also list below all mcmbers;-if arty, which are legal entities. If
there arc no such members, writc'"no members." For trusts, estates or other similar entities, list below
the legal titlcholdcr(s). , ,. .< .:.¦ ,
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership.vpr joiiit venture, Jjsj|.bjBlp^t}]:pAnam^i.a^dlitle of eabh•jgenpralt^artn^r,managing member, manager or any Other person or. entity (that controls ^ Party. NOTE: Each legal enfity listedlbc^
Name
Frlltz L. Duda. Jr.
Title 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% ofthc Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary ot 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
Fritz L. Duda, Jr. 980 N Michigan, Suite 1280 " _.;%
Elise A. Gibson Chicago, IL G0611 L ;%
Duda Children's Trust No. 1 i %
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 -{/I No
If yes, please identify below the name(s) of such City elected official(s) and describe such
rclationship(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 ofthc fees paid or estimated to be paid. The Disclosing Farlyjs no.t required to disclose employees who arc 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-rprofit 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 cither ask the City whether disclosure is required.or make the disclosure.
Page 3 of 13
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)
D^ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities SECTION V — CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under 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 [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
•If-1'Yes," has tlie person entered for payment of all support owed and
is the person in compliance with that agreement?
[•] Yes " []Nb '; ' *' ' " !' ' '
FURTHER CERTIFICATIONS • >, - : j ;
I. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.gv"dbiri'g'b^ if the Disclosing Parly
submitting this EDS is the Applica'nEand is doing bus'ihcss'with thc City, then thc'Disclbsirig Party certifies as follows: (i) neither the Applicant rior any'cohlrollihg 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) ihc 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, (he permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below
Page 4 of 13
2 The Disclosing Party and. if the Disclosing Patty is a legal entity, all of those persons or entities identified in Section I.l.B.l. of this EDS:
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntanly excluded from any transactions by any federal, slate 01 local unit of government;
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;
are not prcsenlly-indictcd for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause 13.2.b. of this Section V;
have not, within a fivc,-ycar period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, within a fivcTyear 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 3j.4 and 5 concern:
« the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in-connection with;theMatter,'%^udirig b.ut not limited to all persons or-legal entities disclosed.under. Section IV, "Disclosurc;of.Sub,cpntractors and Other Retained Parties");
any "Affiliated £ntity.^(mea^^ 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; commonuscof 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 Parly, any Contractor or any Affiliated Entity or any other official, agent or employee ofthc Disclosing Parly, any Contractor or any Affiliated Entity, act ing 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 cither the Disclosing Party 01 any Conttactor nor any Agents have, during the five years before the date this EDS is signed, 01, with lcsped to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the Five years before ilic date of such Contractor's or A ffiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthc City, the Slate of Illinois, or any agency of the federal government or of any state or local government in the United Slates of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom'of competition by agrcemcnt.to bid a fixed price or otherwise; or
made an admission of such conduct dcscribcdin:a. or b. above that is a'matter of record, but have not been prosecuted for such conduct; or-
violated .-the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with anyunifof 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,offens'erof-any state or ofthc United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither'the.Disclosing Party nor any Affilfated'Entily. is listed on.any of the following lists maihtaiiicd.fby.the " Office of Foreign 'Assefs'Go"ritrdl^6f:the ;UVSV.E^ep^rtment-.pf-.the Treasury or the Bureau of Industry and Security of 1he''U.;S.iDc'paftib;crif of'.G.oi^mXrCc'^r.:th:eir-succcssors: the Specially Dcsignatc&NationalsrList; the Denied-Persons'IrfsV^
Debarred'L-ist." .v '•'' "'^
6. • The Disclosing Party understands and shalf coihjlly witlfithe applicable requirements of Chapters
2-55 (Lcg^slativclrispector General), 2-56 (Insp;cctor.'Gencrai)and'2-i;56 (Governmental Ethics) ofthc
Municipal Code. •'
7. If the Disclosing Party is unable to certify to any ofthc above statements in (his Part B (Further
Certifications), the Disclosing Party must explain below: N/A
Page 6 of 13
If the letters "NA." the word "None," or no response appears on the lines above, it will he conclusively presumed that the Disclosing Party certified lo the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 1 2-monih period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, lo an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below,.please also list the name of the City recipient.
N/A "
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is \/\ is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the'Disclosing Party pledges:
"We arc not and will not become a predatory lender as defined in Chapter 2-32 ofthc 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 ofthc 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):
Page 7 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 ceitified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthc Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-1 10 ofthc Municipal Code: Docs any official or employee ofthc 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 [/j No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in "the name of any other person or entity in the purchase of any property 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 ptursuant to the City's eminent domain power docs not constitute a financial interest within the meaning of this'Part D.
Docs the Matter involve a City Property Sale?
[]Ycs (/I No
If you checked ''Yes1' to Itcrh'D.l., provide the'dame's 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.'Earty.-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 cither 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
Page 8 of 13
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
• ' be Disclosing Party verifies that the Disclosing Parly 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 lo or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Parly verifies that, as a result of conducting the search in step I above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that-thc.following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FErp'ERALLY 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 tliis Section VI, tax credits allocated by the City and proceeds of debt obligations of the City arc not federal funding.
A. CERTIFICATION REGARDING LOBBYING
I. 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):
(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, anofficer or employee of any agency, as defined applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of 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.
Page 9 of 13
The Disclosing Party will submit an updated certification at the end of each calendar <.ju.-iii.cr in which there occurs any event that materially affects the accuracy ofthc statements and information set forth, in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that cither: (i) it is not an organization described in section 501(c)(4) ofthc lnternal'Revcnuc 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".
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 jiiiy subcontract and the Disclosing-Party must maintain all such subcontractors' certifications for the duration ofthc Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally.funded, federal regulations require the Applicant and all proposed subcontractors to submit-tfie''following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[]Ycs []No If "Yes," answer the.three gucstipns.^elpw:
Have you dovelo^^ahd'd^ydii"have-on'file affirmative action programs pursuant to applicable federal regulations? (Sec 41 CFR Part 60-2.)
[JYcs []No
Have you filed with the Joint Reporting Committee, the Director ofthc Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under thciap'plUcable^fiiing" requirements?'*1' *
[ J Yes' ' ' '"¦-'''>- [fNo" ;;
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[] Yes • • |"]No
If you checked "No" to.question 1. of'2. above, please provide an explanation:
Page 10 of 13
SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Parly understands and agrees that:
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 arc material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Parly understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
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.orR/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (3 12) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the^ City .determines that any information provided in this EDS is false, incompleteor 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 cohtract 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. - : •-• V'v'''-\.^-.',
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 InTqrmatipn.'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 kepi cUrrcnt. 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-lhc City's Department of Procurement Services, thcrD.isclosing Party must
updatcihtsEDS 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:
Page 11 of 13
)•".!. The Disclosing Party is not delinquent in the payment of any lax administered hy the lllino is Department of Revenue, nor arc the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, lax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, properly iaxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Parly and its Affiliated Entities will not use, nor permit their sitbcontractors'.io use, any facility listed by the U.S. C.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 believe1" lias'hot provided or cannot provide truthful certifications.
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 (ifapplicaJblejrOnibehalf of the Discldsing:Party, and (2) warrants -that all oertiGcatiptos-and statements•contaifie'd .|iji-&is.EDS and Appendix A (if applicable) arc true, accurate and complete.as:of the date furnished;to.the;.City.
Elgi'FPQJllVgstment Company LLC^... (Prin(- or', type 'name of bisclds^g^arlty'j'
(Sign here)
'FrlfeE/'&ida, Jr. - . - . ;:i
(Print pntype name of,>pcrsomsigning)
Manager'
(Print or type title of.person signing)
S^gncd-and swom to before mc on (date) 'Q'-QilL>\JiQ QjH*<4 t Notary Public.
Commission expires: Cr)'~\ i f *-t ')¦¦).•
Page 12 of 13
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) Che Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not lo 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 Parly 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 ofthc Disclosing Party listed in Section ILB.l.a., if the Disclosing Party is a corporation; ad partners of tlie Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limitcdpartncrs of tire Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthc 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.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" withan electe^'dty official or department head?
[ ] Yes .t/]*Io
If yes, please identify below (I) 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 tlie 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 APPENDIX 1?
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
Tliis Appendix is to be completed only by (n) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (nn "Owner"). It is.noi to be completed byntiy legal entity which has only an indirect ownership interest in the Applicant.
Pursuant.to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthc Municipal Code?
[ 3 Yes . tyrNo
-If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Yes [ ]No "fT] Not Applicable
If yes to (I) Or (2) above, please idcntify'bejow (he-name ofthc person or legal entity Identified as a building code scofflaw or problem landlord and the address ofthc building or buildings to which the pertinent code violatton^apply,
.FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS iNCORPORATED BY REFERENCE INTO, AND MADE A PART'OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTDFTCATTON MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your KDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new BDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3985 N Milwoukeo/4871-4777 W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below: (l) warrants that
he/she is authorized to execute this EDS recertification on behalf of Uic Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as of the date furnished to the City and continue to be true,
accurate and complete as of tlie dale of this rccertification, and (3) rcaffinns its
acknowledgments.
Flatiron Investment Compancy LLC
(Print or type legal name of Disclosing Party)
By:
(sign here) Print or type name of signatory:
Frltz L. Duda, Jr.
Title of signatory:
Manager
Signed and swom^to-before mc on [date] Q. \ 1 fl 1 1 Lt , by
\~<-v \?7L-"TX^ckcv."JV, at £ e„£>tCL County, T:l
Notaiy Public.
Commission expires: Lj ,| {H \ .{>y
OFFICIAL SEAL
ANEL-MEDINA NOTARY PUBLIC, STATE Of ILLINOIS My Commission Expires April 14,2017
v *p \f v v \j »
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/n/ if applicable: CSD Six Corners Member LLC
Check ONE ofthc following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
L/5 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: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) Slate'ihe legal name of the entity in
which the Disclosing Party holds a right of control: _ \
B. Business address of the Disclosing Party: 980 North Michigan, Suito 1280
Chicago, IL 60611 ...
Email: jcollins@clarkstreot.com
Telephone':-(312)377-9111 Fax:
Name of contact person: John Collins
Federal Employer Identification No. (if you have'oric): __ ._ ^_ ' ¦'" ' ' . ¦
Brief description of contract, transaction or othcrundcrliiking-(rcfcr'rdd id below as'thc "Matter") to which this EDS pertains. (Include project number and location'of property, if applicable):
Zoning Amendment for property located at 3911 -3985 North Milwaukee Avcnuo; 4671-4777 Wost Irving Park Road
G. Which City agency or department is rcqucsting-this EDS?£f]P.__i
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification Ii ^ :__.and Contract.// , , • ._
Page 1 of 13
SECTION 11 - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation (Is 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, .. . .J/J N/A
F3. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below, the full names and titles of all executive officers and all directors of the entity. NOTE: For not-fprrprofit corporations, alsoTist 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 ritleholdcr(s).
If the entity is a general partnership.'dimitcdip'artnership,.limited liability company, limited liability .
partnership or joint venture, 4isfbelow' the name and title of each general partner, manag'ing.mcmber,
manager or any plher.perso^ Disclosing Party.
NOTE: EachlcgaUcntityfliste sUbniitan;EDS. on. its own behalf. . ,
Name
E. Thomas Collins, Jr.
Title
Manager
Richard E. Hulina
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,
Page 2 of 13
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 ofthc 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
Please see Exhibit A
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of thc Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes ¦ - • ¦<-¦¦ ,f/j No
If yes, please identify'bclowitheinamc(s) of such City elected officials) and describe such . rclationship(s): >
SECTION IV -- DISCLOSURE O^SUBCONTRACTORS AND OTHER RETAIN ED P ARTIES
ThcDisclosing 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 arc paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person pr.:ciUityw.ho. undertakes .to influcn dr admihistrative
action.on behalfof any-person .'or .'entity other than: (I) a not-for-profit entity, on an'.unpaidi .basis, or (2) himself. "Lobbyist" also means any;pcrsoh or entity any.part of...whb.se 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 Sec tion, :the . Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business Relationship lo Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rale" 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 " CERTIFICATIONS :
A: COURT-ORDERED CHILD SUPPORTCOMPLIANCE •
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 tlie 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 ^v^d person directly or indirectly owns 10% or more of the
Disclosing Parly.
If "Yes;" has'thc.pcrsori entered into a'co'uffo support owed and "
is the person.in compliance with that agreement?
[ J Yes UNo "'" ' : ¦
B. FURTHER CERTIFICATIONS ^ ' ;; V ' "
1. PursuanUo.Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should cons.uUTbrTae'fi^ea terms;-(c'.g:,''"d6ihg'b"u^
submittihg'ihis' Eps is the Applicantaiid is doing"business with thc'Gity, then"the'Disclosing^Party'
certifies as':f6iiows: (iyh'cither th indicted'o"r 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, perjtiry, dishonesty or deceit/against aifb'fficer or 'employee"of the'City or any sistcr agency;-arid(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
entitled in Section 11.B.I. of this EDS:
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, 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;
arc 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;
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
c. have not, within aTive-ycar: 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.cnVironmcntal Violations, instituted by the City or by the federal-government,
3, The certifications in subparts'3, 4 and 5 concern:
the Disclosing Party;
any "Contractor" (meaning any .contractor or subcontractor used by thc;Disclosing Party in .y connection with'thCfMaVter^inciuding'but not limited:to„all persons or legal cntitics.discloscd under -Section IV, "Disclosure of Subcontractors and Other. Retained Parties");
any "Affiliated Entity? ;(meaning' apcrson or entity-that; directly orindirectly: controls.the ,., .
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of anothcrperson or. entity. Indicia of control include, without limitation:
interlocking.inanagcincntvordwricrsh .among family, members, shared facilities
and equipmcnt; common:usc of employees; or organization of a business entity fpllowing the ,,
ineligibility of a bu6incs6 entity to do business with federal or state or local govcmm'erit,-including:
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractor^. the'term Affiliatedindirectly 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 ofthc Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Parly, 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 orengagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe; a "public Officer of employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in lhc United States of America, in that officers or employe'e's.official capacity;
agreed or colluded with other bidders or prospective bidders; or-been a party to any such ' agreement, or.becn convicted or adjudged guilty of agreement or collusion among bidders or prospective'bidders; in restraint of freedom of compctidqn.by agreement to bid a fixed price or otherwise; or
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
violated;tHc'lprovisiqn's--6f Municipal'-Code Section-2-92-610'(Living Wage Ordinance).
A. Neither.-the D'isclosiftg'Party', Affiliated Entity or Contractor'; prVariy of.thcir,employees;officials, agents or partners, is barred from contracting with any unit of slate or local government us 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 df America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neijtlick^ Affiliated-Entity is'ilist^
mainfainediby the Office of Foreign Assets Control of ihe U;S: Pepaftrnc'nt of the Treasury or the
Bureau of Industry and• Security. of ;the U.S. Department of Commerce .or ^their .successors: the Specially
Dcsignatcd^alionals^st;^ Eist,the!Unverificd'List,;;thc Entity;List:ahd.thc
Debarred List. - .¦/'/ "¦'' '' ¦ ¦ ¦¦¦¦¦ " ¦"'
-•'6:--^tBc1P)scidsihg;-P and shall'co'mply witlv'th'c applicable
2-55 (Legislative Ihsp'ccT6f'*G'enerai)V2-56 (Inspector General) and12-156 (GOvcrnmentai 'Ethics'):6f the
Muriicipal'Co'de " ' •''¦'"" '¦' . : ' ' : •:.';¦ .
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), thcibisclosirig Party-must explain below: N/A
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.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthc Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthc City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees -or to 'the 'genera 1 public" of (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate' with "N/A" or "none"). As to any gift listed below, please also list the name ofthc City recipient.
• N/A • " ' ' ' ¦ '"- ~ ~ ~ -
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Purty (check one)
[ ] is f/\ is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
.If the Disclosing Party IS: a financial institution, then the Disclosing Parly 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 ofthc Municipal Code, explain here (attach additional pages if necessary):
Page 7 of 13
If illc 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 arc defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D;
In accordance with Section 2-156-110 ofthc Municipal Code: Does any official or employee of the City have a.financiaPinterest:in:his or her own name or in the name of any other person or entity in.the Matter?
[} Yes'. . Vj N°. • '.
NOTE: If you checked "Yes" to: Item D- L, proceed to Items D.2. and D.3. If you checked "No" to Item D.l :,:.procccd:;to Part.
Unless sold pursuant to a process of compctitivebidding, or otherwise permitted, no City elected official or cmploycc shall have a financial interest in his or her own name or in'lhc name of any other person or entityWthc purchase of any property that (i) belongs to the City, or (ii) is sold for taxesor assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). CompcnsatiqnTorproperty taken pursuant to the City's'e.mmcnt.dqmain:pqw,er does not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City'Property Sale?
I ] Yes f/j No
If you checked "Yes" to Item'D.l., provide the names and business addresses of the City
officials or employees; hay ^ identify'the nature of-such interest:
Name ; ... BusinessAddress . Nature of Interest , ,.
4. The .Disclosing PartyTurther certifies .that no prohibited financial interest in the Matter will
be acquired'by any Ci.ty.d/ficialb.r.^mplbycc.- ' '
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Parly must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13
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 und all slaves or slaveholders described in those records:
SECTION VI -- fiERTIFlCAf IONS 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.procceds 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):' =.'
(If no explanation.appears or begins oh the lines above, or if the letters "N A" 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 pr.attcmptto 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.
Page 9 of 13
Tlie 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 ofthc statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section . 501(c)(4) 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 erigaged'and will not engage in "Lobbying Activities".
If the'Di'scldsing Pahy is the Applicant, the Discldsing'Pa'rty musi obtain certifications equal in form and substance to parag>aph'^A:;lv4h>bu'gh A.A\ above from all subcontractors before it awards any subcontract and'tlie'bis'clos'irigParty-must-maintain all such-subcontractors' certifications for-thc •¦¦:' *• duration of the Matter and must make such certifications promptly available lo the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally-funded;.fedcralTcguU and all proposed
subcontractors to submit the following information with their bids of in writing at the outset of
negotiations.... ¦ ,.t ,.
Is the Disclosing Party the Applicant?
[) Yes [ ] No
If "Yes," answer the threc.qucstions below:
Have you developed and do you have on file 'a'ffirma'liv'e.kctioh programs pursuant'tb applieabie federal regulations? (See 41 CER Part 60-2.)
[ ] Yes [ J No- ' •
Have you filcd'with the['] Yes', V"*''.M'!*' f ]M Cf "!'" ; " ' ' ;
Have you participated in any previous contracts or subcontracts'subject to the equal opp.ortunity clause?
['] Yes :V- [ jNo' ' 1
If you checked "No" to question 1 . or 2. above, please provide''an explanation:
Page 10 of 13
SECTION Vir- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
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.
The City's Governmental .Ethics and 'Campaign'-Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, imposc certain duties and obligations on persons or entities seeking City contracts, work, business, prtransactions. The full text of these ordinances and a training program is available on line at www.citvofchicaRo.orti/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the City determines that,any:information provided in this EDS is false, incomplete or.inaccuratc, any contractor.ptndragreerticnt in connection with.which it is submitted may be rescinded or'bcjyoid or voidable, knd'&e^Ciry-7m'ay pursue-any remedies under the contract or "agreement "(if not rescinded pr 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 transaetions with the City. Remedies at law for a false statement of material fact may include incarceration and an award tq'.the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site.and/pr-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'-bf Information Act'requcst, 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 pubUc^rclea^efpf'information contained in this EDS and also authorizes the City to verify the accuracy of tiny information submitted in this EDS.
The information provided in this EDS must.be keptcurrent. In the event of changes; the-Disclosing Party must supplement this EDS up to the time thc 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-thc conU-act/requires. NOTE: With respect to Matters subject to Article Lof Chapter F-23of thc Miihicipl"Gpdc (imposing PERMANENT INELIGIBILITY for certain specified offenses), the!information provided herein regarding eligibility must be kept currcnt for a longer period, as required by Chapter l-23fahd! Section 2-154-020 ofthc Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
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, lax 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 (fixes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use.'iior permit their subcontractors to use, any facility ilisted by the U.S. E.P.-A. on the federal Excluded Parties List System ("-EPLS") maintained by the U. SGc'ripral 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 Ihc Matter certifications equal in form and substance to.those in;F,l. and F.2. above andwili not, without the prior written consent of Ihe City. jUsc any such contractor/subcontractor that does not provide such certifications' or that the Disclosing Party treason to believe has not provided or cannot provide truthful certifications:
NOTEiilf 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
Wnd;.er penalty, o.fpc^
ih'>s}EDS'aiid AppenHixA on behalf ofthc Disclosing Party,:and;(2j;warranis;tnaia]l
certifications andstatemcnts contained in this EDS and Appendix A (if-applicable) arc true, accurate' andxqmplete ;
¦¦•CSjDiSl'x;Gqme'rs;Mem^ : .' ' ' ; ' '
(Print oj^yr^'ntt/nc'bf Disclosing jjuriy)'
...(Prihtjoj-type;hamci,qf(pcison:signing)
:Mahagor';pf GSbsix'CornWsM (Print dr type title of person signing)
¦¦ Sigrictfah^'Sw'itrnitfbefore me on (dale) f")\ \ Q£>) 1^
Ch^0 t~ County. TX~ j (state). '
Public;
Commission expires: £)W // *J //~7
Page 12 of 13
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) (he Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not (o 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 tins.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, wheth'er-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 stcpdauglitcr.'stcptirothcr or stepsister or half-brother or half-sister. '" ¦' 1 7
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section Il.B.l.a,, if the Disclosing Party is a corporation;.all partners of the Disclosing Party, if the Disclosing Party is a general partnership;1 all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthc 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:pcrson exercising similar authority.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] 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 nairi'e and title ofthc 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
EXHIBIT A CSD SIX CORNERS MEMBER, LLC
Colllns; Family Limited Partnership :%
Hulina Family Limited Partnership | 1%
Clark Street Deyelppment LLC ... <%
Flatlron Investments Company LLC ; %
jMKinterestSi;LLC . . , %
Peter Elsenbe'rg. ... ,. %
JEC Investments, LLC .-. . ,:[,-., %
AndrewStelh '.-'.j % .,
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX B
BUILDING CODE SCO FIT, AW/PR 0 B LEM LANDLORD CERTIFICATION
Tills Appendix is (o be completed only by (n) the Applicant, and (b) any Icgn.l entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (nn "Owner"). It is not to be completed by any legal entity which lins only an Indirect ownership interest in the Applicant.
I. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code? '
[ JYes
2. -If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified ns a building code scofflaw or problem landlord pursuant to Section 2-92416 of the Municipat Code?
I ]Ycs
3. If yes to (1) or (2) above, please identify below the name ofthc person or legal entity
identified as n building code scofflaw or problem landlord and the address of the building or buildings to which (he pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDDC B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADETN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City.procurements unless requested.
This recertification is being submitted in connection with 3911-3905 N Milwaukee/4071-4777 W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below: (I) warrants diat
he/she is authorized (o execute this EDS recertification on behalf of the Disclosing Parry, (2)
warrants-that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as ofthc date furnished to the City and continue to be true,
accurate and complete as ofthc date of this rccertification, and (3) reaffirms its
acknowledgments.
CSD Six Corners Member LLC (Print or type legal name of Disclosing Party)
Print or type name of signatory:
Richard Hulina
Title of signatory:
Manager
.Signed and sworn to before mc on [date] jff /i/ (a| I , by
ftiCikacA \A-vA uxjty. at jQ^cx\C~. County, j^j Lstot°]-
i jj f\ Notary Public.
Commission expires: £f j/*//l *7 •
OFFICIAL SEAL iinr ANEL MEDINA NOTARY PUBLIC. STATE 0FIUJN0IS Wwmton^s IK 2017:
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SEC TION 1 -- GENERAL INFORMATION
A. Legal name of Ihc Disclosing Party submitting this EDS. Include d/b/a/ if applicable: Blackfriars Corporation
Check ONE ofthc following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
D/j a legal entity holding a direct or indirect interest in (he Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest: CSD Six Comers LLC
OR
3. [ ] a legal entity with a right of control (sec Section 11.13.1.) State the legal name ofthc entity in
which the Disclosing Party holds a right of control:,
13. Business address of the Disclosing Party. 555 Skokie Blvd, Suite 555
Northbrpok, IL 60062
Telephone: (847)313-6454 Fax: (847)498-7893 Email: mbattln@eblxby.com'
Name of contact person: Michael Baffin
Federal Empioyerldentificatioh No. (if you have one):... ., .
Brief description of contract, transaction or other undertaking (referred to.bclpw as.the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Zoning Amendment for property located at 3911-3985 North Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS? P_£P_ ___
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification tt and Contract ft ¦
Page 1 of 13
SECTION II — DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF Till: DISC LOS I NO I'ARTY
1. Indicate; the nature ofthc Disclosing P; [ ] Person
[ ] Publicly registered business corporation [X] Privately held business corporation ( ] Sole proprietorship [ ] General partnership [ ] Limited partnership [ ] Trust
( J Limited liability company | ] Limited liability partnership [ ] Joint venture | ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
I J Yes [JNo [ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization,'if applicable:
Delaware
3. For legal entities not organized in the State of Illinois: lias the organization registered to do
business in ihc Stale of Illinois as a foreign entity?
M Yes []No (' J N/A
13. 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 rhembcrs, if any, which arc legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titlelioldcr(s).
If the entity is a general partnership, limited partnership, limited liability company, limited.-liability partnership or joint venture, list below the hamc and title of each general partner, managing m'chibcr, 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 ownbehalf.
Name Title
Keith W. (Colburn President
Richard W. Colburn Vice {'resident
David Bradford _____ . Sceictai y _ _
Kuril a-her _ _.'i'ixa£ura _ .-.
David Vcrbcck Assistant Secretary
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.
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. Jf 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 Parly
Keith W. Colburn 555 Skokie Blvd, #555 _ 33_ _ "
Richard W. Colburn Northbrook, IL 60062 __¦ 33
Carpi C. Grigor 33
SECTION I'll -- 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 1 2 months before the date this EDS is signed?
UYcs f/j.No. . . .
If yes, please identify below the.namc(s) of such City elected official(s) and dcscribe.such
rclattonship(s): . , ¦¦
SECT!QN 1V -- D1SCLOSURE.OF,SJUBCONTRACTORS AND OTHER REGAINED F ARTIES
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 ofthc fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Parly's regular payroll.
"Lobbyist" mean's any person or entity .who undertakes lo 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 Parly must either ask the City .whethcr disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business retained or anticipated Address to be retained)
Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NOTE: "hourly rale" or "f.b.d." is not an acceptable response.
(Add sheets if necessary)
L/| Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under 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'^ 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 f^5 No [ ] No person directly or indirectly owns 10% or more ofthc
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?
FURTHER CERTIFICATIONS ' ¦ '¦
1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article I")(which the Applicant should
consult-for fo^ "doing business") arid legal requirements), if thc'DlscTp'si'rig'.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 ihdic'tcd'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 dc'ceit'against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Pago 4 of 13
The Disclosing 1-'any and. if the Disclosing Party is a legal entity, all ofiho.se persons or entities identified in Section 11 B 1. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, slate or local unit of government;
have not, within a five-year period preceding the dale 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 n public (federal, stale 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;
arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with comrniiling any ofthc offenses set forth in clause B.2.b. of this Section V;
have not. within a five-year period preceding the dale of this.EDS, had one or more public transactions (federal, slate or local) terminated for cause or default; and
c. have not, within a five-year period preceding the dale of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The 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,, includirigout not limited to all persons or legal entities disclosed under
. .Section:! V,."Disclosure of Subcontractors.and,Other, Retained .Parlies**); ,
any "Affiliated. Entity" (meaning a person or.entity thai, 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 slate 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;mcans a person or entity that directly or indirectly controls the Contractor, is controlled by it,'or,-wilh the Contractor, is under common control of another person or entity;
• any responsible official ofthc Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthc 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'1).
Page 5 of 13
Neither Ihc Disclosing Party, nor any Contractor, nor any Affiliated Entity of cither 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 P.ntiiy, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's conlraci or engagement in connection with Ihe Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthc City, the State of Illinois, or any agency ofthc federal government or of any stale or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or becn'a party lo 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 lo bid a fixed price or otherwise; or
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
violated Ihe.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 stale 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 ofthc United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor'any Affiliated Entity is listed on any of the following lists
maintaincd'byithe Office' bf'Foreign Assets Control of the U.S. IJcpartmehrbf the Treasury or'the.
Bureau of Industry and Security bftlic-'U.S/Dcpartmeiit of Commerce "or .'their succcssorsiTlic^Spccially
Designated Nation^ Persons List, the Unverified( List, the Entity List and the
Debarred ListW . -; ' ' '¦''¦¦¦!•• • ¦'¦' ¦¦¦"''¦
The blsclbsihg'Party-uhdc'rsiahds''aiKl'sliall comply with The applicable-requirements of Chapters
2-55 (Legislative lhspector Geheral)'. 2-56 (Inspector General)'arid '2-1 56 (Governmental Ethics)'of the
MuriicipaPCodc. ':'¦'• ¦ ¦ .-¦
Ifthc Disclosing' Parly is unable to certify to any of the above statements in this Part 13 (Further Certifications);.the/Disclosing-Partymust explain below:
Page 6 of 13
If the Idlers "NA," the wo id "None." or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best ofthc Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Parly who were, at any time during the 1 2-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
None
9. To the best of ihc Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any lime during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago, for purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or 10 the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthc City recipient.
None '
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
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.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc not and will not become a predatory lender as defined in Chapter 2-32 ofthc Municipal Code. Wc further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of Ihe 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 withinthe meaning of Chapter 2-32 ofthc Municipal Code, explain here (attach additional pages if necessary):
Page 7 of 13
If llic letters "NA," the word "None," or no response appears on the lines above, ii will be conclusively presumed thai the Disclosing Party certified to ihc above siavemems.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms thai arc defined in Chapter 2-156 ofthc Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-1 10 ofthc 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 . p<] 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 lb. Part E. . ,
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any properly that (i) belongs (o 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 Properly 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.
Docs the Matter involve a City Property Sale?
[ ] Yes IX] No
If you checked "Yes" to Item D.l., provide the names and business addresses ofthc 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 cither 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to ibis EDS all information required by paragraph 2. Failure lo
Page 8 of 13
comply wild these disclosure requirements may make any conlract entered into with the City in connection with the Matter voidable by the City
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 lo slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Parly has found no such records.
_2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Parly has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in .those-records:
SECTION VI --CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: 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 ofthc City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
I. 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):
(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 ihe Disclosing Party means that NO persons orcntitics registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with-icspcct to thc:Matlcr.) ....
2. The Disclosing Party has not spent and will not expend any federally apbrop'riatcd.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.
Page 9 of 13
The Disclosing Parly 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.
The Disclosing Party certifies that cither: (i) it is not an organization described in section 501 (c)(4)'of the Internal Revenue Code of 19S6; or (ii) it is an organization described in section 501(c)(4) ofthc Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Parly 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 ii awards any subcontract and the Disclosing Party must maintain-all such subcontractors' certifications for the duralion.of the Matter and must make such certifications promptly available lo the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Mailer is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following infomVatioh;with their bids or'in writing at'thc outset of negotiations.
Is the Disclosing Party the Applicant?
[ ] Yes ( 1 No
If "Yes," answer the three questions below:
1. " Have you developed and do you have on file-affirmative action programs pursuant lo applicable
federal regulations? (Sec 41 CFR Part 60-2.)
[] Yes []No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance-Programs, or the Equal Employment'Opportunity Commission all reports clue
under the applicable filing requirements? , . . . .
iVcs'* ' ; " ''-' ' |' ] No • .
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes '¦' [ ] No
If you;chcckc'd "No" to question I. or 2. above, please provide an explanation:
Page 10 of 13
SEC TION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENAL TIES, DISCLOSURE
The Disclosing Parly understands and agrees that:
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 arc material inducements to the City's execution of any contract or taking other action with respect 10 the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental'Ethics 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/Elhics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Parly must comply fully with the applicable ordinances.
If the Cily determines that any information provided in this EDS is false, incomplete or inaccurate, any 'contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under (he contract or agreement (if not rescinded or void j; at law, or in equity, including terminating the Disclosing Party's participation in the M-itttcr and/or declining to allow the Disclosing Parly 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 Cily of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided 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 AcLrcqucsl, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any.pqssible rights or claims which it may have against the Cily in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information 'submitted in this EDS.
The information provided in this EDS must be kept current In the event of changes, the Disclosing Party must supplement this EDS up to the time the Cily 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'lo Article I'-of-. Chapter 1-23 ofthc Municipal Code (imposing PERM ANENT 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 2-1 54-020 of the Municipal Code. ¦ ¦
The Disclosing Party represents and warrants ibat:
Page 11 of 13
I'.l The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of" Revenue, nor arc 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 Uie Disclosing Parly is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor pcrmit.lheir 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-substancc to those in F.l. and F.2. above and will not, without the prior, written consent ofthc City, use-any-such"contractor/subcontractor that docs not provide such certifications or that the Disclosing Party.has.reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any ofthc 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.thatjic/shc .isauthori7.cd to execute
ihis-EDS and Appendix A (if applicable) on behalf of thc. Disclosing/Party, and (2) warrants that all
certifications^^ contained in this EDS and Appendix A (if.applicable) arc triic,.accurate
and.complcte as of thc date furnished to the City.
Blackfriars Corporation
(Print or type name of Disclosing Party)
By^jte:.____________ :. ... '.,,..;¦
(Sign here) . . ... v
KoidfVV; Colburn' , (Prinf'or.typcmamc ofperson signing) President
(Print ordypc titlc o.f.person signing)
Signed and sworn to-.before mc.on (date)^/i>jerxh0s±jc£^.t^J!6L.i
at JooJL,.., County, jn;4^aii_ (state). .
<-^^_jlW'JM~. /7)\-CjX-~*WJ. Notary Public. { . OFFICIAL SEAL
J V I i KIM8ERLY M BANKS >
& Notary Public - Slate ol Illinois >
Commission expires: UrlA^ALh _- I My Commission Expires Jun 13. 201.6 :,
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is lo be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to he 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 ofthc date this EDS is signed, the Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof is related 10 ihc mayor, any alderman, Ihe 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, molhcr-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (I) all executive officers of the Disclosing Party listed in Section II.B. 1 .a., if the Disclosing Party is a corporation; all partners of the Disclosing Parly, 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) ihe name and. title of such person, (2) the name of the legal entity lo which such person is connected; (3) the name and title of the eleclcd 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 APPEND FX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
Tin's. Appendix is to be completed only by (a) the Applicant, and (b) any. legal.entity which has n direct ownership Interest in the Applicant exceeding 7.5 percent (an "Owner"). It-is not to be completed by nny legal entity which has only au Indirect ownership/Interest in the Applicant.
Pursuant to Municipal Code Section 2-154.010, is the Applicant or anyOwner,identified as a building code scofflaw oivproblcm landlord pursuant to Section 2-92-416 ofthc Mtinicvpai Code? .
I ]Ycs NxTNo
-If the Applicant is a/legal entity.publiclylra'dcd.oh.any exchange, is any qffice'r.or director of the Applicant identified n's a building code scofflaw or problem' landlord pursuant to .Section 2-92-416 of the Municipal Code?
( ]Ycs [ ]No ^J) Not Applicable
If yes to (I) or (2) abovc,.pJease.idcntify below the name ofthc person or legal entity,
identified^ landlord and the address of the building or
buildings' to wliich the pertinent .code violations apply,
FELLING OUT' THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PAJvT OFy THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO TIIE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3985 N Milwaukee/4871-4777 W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that
he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as of the date furnished to the City and continue to be true,
accurate and complete as ofthc date of this rccertification, and (3) reaffirms its
acknowledgments.
Blackfriars Corporation Date: fj,^
(Print or type legal name of Disclosing Party)
By:
&«
(sign here)
Print or type name of signatory: Keith W. Colburn
Title of signatory:
President
Signed and sworn tobefore me on [date] (^JquAC/:.^.
iua^ OJ- Q/mmaJY -- at Ceo k~ County, ^~//!>w <~>
Notary Public.
Commission expires:
V»r. II-01-flS
USA M TOMASEttO OFFICIALSEAL Notary Public. Slate of Illinois My Commission Expires Novcmbsr 12, 2018
CITY OF CHICAGO ECONOMIC DISCLOSURE STATKMENT AND AFFIDAVIT
SECTION I GENERAL INFORMATION
A. Legal name of the Disclosing Parly submitting this EDS. Include d/b/iW if applicable:. The Duda Children Trust No 1
Chech ONE of the following (lu ce 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: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (sec Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
Business address of the Disclosing Party: 980 North Michigan, Suite 1280
Chicago, IL 60611 ¦
Telephone: (312) 377-9111 Fax: hmail; icollins@clarkstreet.com
Name of contact person: John Collins' ^
Federal Employer Identification No. (if you have one): ¦ . . j r
F. Brief description of contract,'transaction or other undertaking (referred lo below. thif "Mattel) ttpJ
which this EDS pertains. (Include project number and location of property, if applicable):
Zoning Amendment for property located at 3985-3911 North Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which Cily agency or department is requesting this EDS? 0Fl> ¦¦ ¦
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # _ and Contract # :
Page I of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[]Yes L] No
Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable: N/A
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?
[]Ycs [JNo . J/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.prother 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 rn ember, manager or any other person or entity that controls the day-tOrday management of the Disclosing Party. NOTE: Each legal entity iistcd below must submit an EDS 6ri'"its'.dwri.^ehalf. "
Name
Fritz L. Duda, Jr.
Title Trustee
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% ofthc Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. Jf none, stale "None." NOTE: Pursuant to Section 2-1 54-030 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
Virginia Marie Duda 980 N Michigan, #1280 1 !%
Elizabeth Grace Duda Chicago, IL 60611 ]%
Fritz Lee Duda III ¦ %
SECTION III -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthc Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[] Yes ' f/No .
If yes, please identify below the namc(s) of.such City elected official(s) and.describc 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 rcquired. to disclose., employees who arc paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or cntitywho undertakes to influence any legislative or administrative action on'bchalf 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.
Name- (indicate whether Business retained or anticipated Address to be retained)
Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.
(Add sheets if necessary)
D/j Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V--CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-41 5, 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 becrt'declared iri arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [/I No [ ] No person directly or iudirectly 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 ' :"' .'. " ; ''
FURTHER CERTIITCATIONS ' " \."'.
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 submittingj'tlnpEDS is the Applicant and is doing business with the City, then ilk.DisclosingVParty certifies as follows: (i) ncithcr'thc 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 ah 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 A rticle 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
The Disclosing Party and, it'the Disclosing Party is a legal entity, all of those persons or entities identified in Section 11.13.1, of this EDS:
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, 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 stale antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any ofthc offenses set forth in clause B.2.b. of this Section V;
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
c. have not, within a five-year period preceding the date ofthis 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 thcfcderal government, any state, or any other unit of local government.
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 ry, "Disclosure of Subcontractors and Other.Retained Parties");
any "Affiliated Entity":(ineaning a person or entity that, directly or indirectly: controls.the Disclosing Party, is controlled by the Disclosing Parly, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation:. interlocking.management or ownership; identity of interests among -family mcinbers,--sharcd facilities and equipment; common use of employees; or organization of a business entity fo.ljowing 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. wilh 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 lintity, " acting pursuant to the direction or authorization of a responsible official ofthc Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Patty, 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:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthc Ciiy. the State of Illinois, or any agency of the federal government or of any slate or local government in the. United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a: or b. above ihat is a matter of record, but. have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
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.offcnsc of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Partymor any Affiliated.Ehtity:is listed on any of
¦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
Page 6 of 13
)f the letters "NA," the word "None," or no response appears on the linos above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best ofthc Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthc Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthc City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, ofthc City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or'(ii) food or drink provided in the course of official City business and having a retail value of less than $20pcr recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient .
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION '
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is (/] is not ^
a "financial institution" as defined in Section 2-32-455(b) of,the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"Wc arc 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. Wc 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 2-3 2-45 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):
Page 7 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.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-156 ofthc Municipal Code have the same meanings when used in this Part D.
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 |/1 No
NOTE:' If yqu checked "Yes" to Item D.l., proceed lb Items D.2. and D.3. If you checked "No" to Item D.l proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name Or in the name of any other person or entity in the purchase of any property 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 docs not constitute a financial inlcrcst within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes (/] No
If you checked "Yes" to item D.l., provide the names and business addresses ofthc 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 intcrest.in the Matter will be acquired by any Cily official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither 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
Page 8 of 13
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by ihe Cily.
^ 1. The Disclosing Party verifies thai 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 eta (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, (he
Disclosing Party has found rccords.of investments or profits from slavery or slaveholder insurance policies, The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: II" 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 th.e.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 respeel to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on'the lines above, or if the letters "NA" or if .the woid. "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 rcspc.ct.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, riiaking 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.
Page 9 of 1.3
The Disclosing Party will submit an updated certification at the end of" each calendar quarter in which then: occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that cither: (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) ofthc Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party'rhust obtain certifications equal in form and substance to paragraphs A.T.'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 Jvlattcr and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally, funded, federal regulations require the Applicant and alf proposed
subcontractors to submit" the'following information with their rjids or in writing at the outset of
negotiations. f ....... ,.. . .
Is the Disclosing Parly the Applicant?
[] Yes I ] No , .
If "Yes," answer the three questions below:
Have you -developed andVdo you havc;on file 'affirmative action programs pursuant to applicable federal regulations? (Sec 41 CFR Part 60-2.)
?•Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under: inapplicable fiiing requirement's? ¦ -.-- ¦ ¦>-
[.] Ycs ; : [ ]No '
Have you participated in any previous contracts or subcontracts "subject to the equal opportunity clause?
[ ] Yes [ ] No ¦ - '; ¦
If y'oii checked "No" to question 1. or 2. above, please provide an explanation:'
Page 10 of 13
SECTION V11 -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part cut'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 arc 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
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations oh persons or entities seeking City contracts, work, business, or.transactions. Thc full text of these ordinances and a training program is available on line at www.cityofchicaKo.orR/Ethics , and may also be obtained from the City's Board of Ethics. 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
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 flic-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., participationin 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.
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 ofthc information provided on this EDS arid 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.
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 DcpartmcntofProcurcrnent Services,.the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters .subject to Article 1 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:
Page 1 1 of 13
F.l. The Disclosing Party is not delinquent in the. payment of any tax administered by the Illinois Department of Revenue, nor arc the Disclosing Parly or its Affiliated Entities delinquent in paying any fine, fee, lax 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 Parly 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. oh the federal Excluded Parlies List System ("EPLS") maintained by ihe U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Parly 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-F.2. above and will not, without the prior written consent of the City; use any such contractor/subcontractor that does not provide such'ccrtificatidns or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an cxplanatory statemcnl must'be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person;signing bclow: ( l ) warrants thathc/shc is authorized to execute this EDS.and.Appcndix. A (if applicable) on-.behalf of the Disclosing Party; and!(2) warrants thai all... ccrtifications and statements contained;.in this'EDS and Appendix A (if applicable) arc true, accurate and completers of the .dale furnishedMoThc City.
The Duda Children trust No. 1
(Print or type name of Disclosing Party)
. (Sign ;h ere) Fritz L Duda, Jr.
(Print or type name of person signing) Trustee
(Print or type title of person .signing)
Signed and sworn to before me on (date) (f>5\ \ Qi=> 1 I
at <~> d> C County;.:_ __; (state).
Commission expires: «—j | ] *—/ ) ^ ^-j
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to he completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 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 die Disclosing Party listed in Section U.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 ofthc 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.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[]Ycs r/]No
If yes, please identify below (1) the name and title of such person, (2) the name ofthc 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
crry of Chicago
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX 13
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix, is to be completed only b.y.(ti)'(he Applicant, and (b) any.legal entity which has n direct ownership interest in the Applicnnt.excecdiug 7.5 percent (tin "Owner"). It is not to he completed by any legal entity which Iins pnly aujndirccl ownership Interest in the Applicant.
Pursuant to Municipal Code Section 2-154;bl0, is the Applicant or any Owner identified as a
building code scoffluworproblcm landlord pursuant to Section 2-92-416 ofthc Municipal
Code? . .
[ JYes i^No
If the Applicant is a legal entity publicly tra'dc'd.p.n any exchange;-is any officer.or director of the Applicant 'identified as';abuilding code scofflaw or problem landlord pursuant toScction 2-92-416 ofthc Municipal Code?
[ ]Ycs [ JNo -js/j Not Applicable
If yes to (1) or (2) above, pleaseidentify below the riainc of the person or legal entity identified as a bujldmg'.cc^e. scofflaw. or.probleml&'nttlb;d and 'the address ofthc building or buildings to v/hich tiie.r^rtincnt cqdc violations apply.
FffjLING OUT TDTS APPENDIX B CONSTITUTES ACKNOWLEDGMENT' AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE RErRESENTATiONS^MAD^ ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3965N Miiwfiukoe-/4871-4777 W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that
he/she is authorized lo execute this EDS recertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as ofthc date furnished to the City and continue to be true,
accurate and complete as ofthc date of this recertification, and (3) reaffirms its
acknowledgments.
The Duda Children Trusl No 1 Date: . Ik.
(Prinl or type legal name of Disclosing Party)
By:
(sign here)
Print or type name of signatory:
Fritz L. Duda, Jr.
Title of signatory:
Trustee
Signed and swom.to before mc on {date] 2_' I • I I * , by
l^t^y- -T^v.Aq v7J>- . at Oc&iZ- County, TT I [state].
\\uAjbjfj^J^juU^ Notary Public.
Commission expires: C| » / *-] > /~7 .
ver. 1,-0.45 J OFFICIAL SEAL
ANEL MEDINA NOTARY PUBLIC,.STATE OF ILLINOIS My Commission Expires April 14,2017
CITY OF CHICAGO l'C C O N O MIC DIS C: I, O SUR E ST AT E M E NT AND AFFIDAVIT
SEC TION I -- GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: E. Thomas Collins, Jr. Irrevocable) Children';; Trust dated 0-1/10/96 on behalf of Lisa Marie
Check ONE of the. following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
\J\ a legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthc
Applicant in which the Disclosing Party holds an interest: CSD Six Corners LLC
OR
3. [ ] a legal entity with a right of control (see Section 11.13.1.) Slate the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 980 North Michigan, Suite 1280
Chicago, IL 60611
Telephone: (312)377-911 Fax: .:. . : ^ Email: jcollins@clarkstreet.com
Name of contact person: John Collins ¦ ¦¦ . ;•
Federal Employer ldcntificatioivNd'.'Tjf-you have one): ',' ' : - • • •
Brief description of contract, trahsactionvor other undertaking (referred to below as the "Matter'') to which this EDS pertains. (Include project .number and location of property, if applicable):
Zoning Amendment for property located at 3911-3985 North Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS? P.°D
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification // and Contract #
Page I of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
I.imited IiabiIity compnny Limited liability partnership Joint venture
Not-Ibr-pro fil eo rporatio11 (Is the not-for-profit corporation also a 50 I (c
[ ] Yes I.J No
| | Other (please specify)
I. Indicate the nature of the Disclosing Party Person
Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership Trust.
2. for legal entities, the state (or foreign country) of incorporation or organization, if applicable: N/A
3. For.lcgal entities not organized in the State of Illinois; Has the organization registered to do business in the State of Illinois as a foreign entity?
I ] Yes [JNo . [/I N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below, the fullnamcs and-tilles of all executive officers and all directors ofthc entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there arc no such members, write "no members." For trusts, estates of other similar entities, list below the legal titlcholder(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 othcr.,persbn or cntity that controls the day-to-day;managenvent of the Disclosing. Party:: NOTE: Each legal.entity.li.sted;bel6;W must .submit an EDS;on ite,o.wh?behaif.
Name
Perry Weinstein
Title
Trustee-
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% ofthc Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13
r
interest of a member or mimager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, slate "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
Lisa Marie Collins 980 N Michigan Avenue. #1280, Chicago IL 60G11 100%
SECTION 111 - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthc Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
(] Yes t/] No
If yes,.please identify:below the namc(s) of such City elected.official(s) and describe such rclationship(s):
SECTION IV r- PISCLPSURE OF SUB C O.NTJRACTORSvAND;0T.HER 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 arc paid solely through the Disclosing Party's rcgujar payroll.
"Lobbyist" means any person or entity who undcrtakcs. 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.cntity.any part of-whosc dutics as an employee of another includes .undertaking to influence any legislative or administrative action.
If.the Disclosing Party is uncertain whether a disclosure's required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the.disclosure.
Page 3 of . 13
Name (indicate whether Business retained or anticipated Address to be retained)
Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "i.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--CERTIFICATIONS
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?
f ] Yes [/\ No [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes;" has the person eritered' ihto-a eburt-approved'agreehienf for payment of all support owed and is the person in compliance with that agreement?
[] Yes [ ]'No ! '*¦¦ ; '
FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article l")(which the Applicant should consult for defihed'terms (c-g.y "dbing business") ahd'iegal'reqiiiremehts), if the bisblbsi'ng' Pafty submitting this EDS is the Applicant and is doing business with'thc 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 actua), 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 1 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.
Page 4 of 13
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.D. 1. of this EDS: L
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, 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;
arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any ofthc offenses set forth in clause B.2.b. of this Section V;
have not, within n 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
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 stale, .or any :other unit of local government.
The certifications in subparts 3, 4 and 5 concern:
? Ihc Disclosing Parly;
* any "Contractor" {meaning-any contractor or subcontractor used by the Disclosing Party in connection \vith.we\Matterifi.nc^.uding.:but not limited to all pcrsons-or.legalentitic.s 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 Partyvis 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_manageincnt„or'p,\Y'nw.ship:; identity of interests amongifamny.rnembe 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 ihc City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that "directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Parly, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, tier any Contractor, nor any Affiliated Entity of cither 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 Malicr:
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 Stale 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; • 1
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record; but have not been prosecuted for such conduct; or ¦ • > . - ¦
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
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-stntc Oribf the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the'Disclosing Party'nbf any Affiliated Entity isiistbd bivany Of the following lists'
inaiiitained-by the Office of Foreign;As'seis;^ U-^DepaHrnchf-o' f -the'Treasury or-the
Bureau of Industry and Security of the the Specially
Designated;;Natibnals List, tlie Denied Persons jjistft^^ List and the ;-
Debarred List. >. . .:... ,. ,;
The Disclosing Pany understands and .shall comply with :thc'applicable r'equircmchts of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector'General) and 2-156 (Governmental Ethics) ofthe Municipal Code.
If the Disclosing Party is unable to certify tp'any of the'above statements' in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
Page 6 of 13
If the letters "NA." the word "None," or no response appears on the lines above, it will be conclusively presumed ihnt the Disclosing Party certified to the above statements.
S. To the best ofthc Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any lime during the 1 2-month period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthc City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best ofthc Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 1 2-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, ofthc City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink, provided in.the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthc City recipient.
N/A
C. CERTIFICATION OF STATUS AS FiNANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is \/\ is not
a "financial institution" as defined in Section 2-32-455(b) ofthc Municipal Code.
If the Disclosing Parly IS a financial institution, then the Disclosing Party pledges:
"Wc arc not and will not become a predatory lender as defined in Chapter 2-32 ofthc Municipal Code. Wc further pledge-that hone 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 Cily."
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 ofthc Municipal Code, explain here (attach additional pages if necessary):
Page 7 of .13
If ihc letters "NA." the word "None," or no response appears on the lines above, it will be conclusively presumed thai the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-1 56 of the Municipal Code have the same; meanings when used in this Part D.
In accordance with Section 2-156-1 10 of the Municipal Code: Docs 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 Hem D.l., proceed to Items D.2. and D.3. If you checked "No" to
item D.l., proceed to .Part E. ' ' ' '
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property 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 po wet-docs not constitute a financial interest within the mcaiiirig of this Part D.
Docs the Matter involve a City Property Sale? ' -
i ] Yes I/I No
I f you checked " Yes"- to Item D; 1., provide'the names ¦and'b'usincss 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 cither 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
Page 8 of 13
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
^ 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 Parly has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in slcp 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:
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, lax 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):
(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 lo 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 n 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 10 extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
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 ofthc statements and information set fori It in paragraphs A.l. and A.2. above.
A. The Disclosing Party certifies that cither: (i) it is not an organization described in section 501 (c)(4) ofthc 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 substancc'to paragraphs A. l .'through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party mtist maintain all such subcontractors' certifications for the duration of the Mattcr'and must make such certifications promptly available to the City upon request.
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. r .......
Is the Disclosing Party the Applicant? ... ; - . -
[ ] Yes [ ] No ... -.
if "Yes," answer .the.,thre.e.:questions:belq\y: .
Have you developed and do you'haveph file affirmative action;prpgr.ajnis,pursuantjo.applicable federal regulations? (Sec 41 CFR Part 60-2.)
[ ] Yes [ J-Nb
Have, you filed with the Joint Reporting Committee, the Director ofthc Office of Federal
Contract Compliance Programs, or the Equai Employment Opportunity Commission all reports due
under the apphcabieifilin^ire^uircrn'cnts?. ' '."."'
n Yes :'/ []Np ~/': ' "J:. ' ' " '
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [:]Np
If yoti checked "No" to question 1. or'2. above, please provide an explanation:
Page 10 of 13
SUCTION VII - ACKNOVVLEDGMKNTS, CONTRACT INCORPORATION, C O M P LIA N C E, PI: NALTIE S, D JSCLOSURE
The Disclosing Party understands and agrees that:
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.
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.cityofchicaKO.orR/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St,, Suite 500, Chicago, IL 60610, (312) .744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the City determines that any information provided in this EDS is false, incomplete orinaccur'atc,
any contract or other agreement in connection with which it is submitted may be rescinded or be void or
voidable, and fhe Cily may.pursue any remedies under the contract or agreement'(if not res'cinded or
void), at law, or iri equity, including tenninatin'g'^ncDisclosihg.P in '¦'the' Matte r:'ahd/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.
Iris the City's policy to makethis 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 Frcedorh of Information Act-request, or otherwise. By.complcling 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 rclease.of^nioYmatibh contained in this EDS and also authorizes the City to verify the accuracy ofany information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to. Article I of . Chapter 1-23 ofthc 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 2-1 54-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
F.l. The Disclosing Parly is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are Ihe Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed lo the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property, taxes or sales taxes.
P.2 If the Disclosing Party istheApplicant, 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 b'c hired in cohnection'witb. the Matter certifications equal in form and'substance to those in F.l. and F.2. above and will hot, 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.
NOTE: If the Disclosing-Parly cannot certify as to any of thcitenis 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^ warrants that ail
certifications-and statements cpnWined}in;'^s.;Ei>S ;'an'd Appendix; A (if applicable) are true, accurate and complete as ofthe.date furnished tp;thc City.'
E. TluMta Cdlr.i, Jr. Umnatb CM4ran'« Tnnld(Print or type name of Disclosing Party) By: (?X(Sign here)
Perry Weinstein, ... -r-.i'..'.... '.v.,.,...
(Print:br.;typc:nanieofperson.signing); ....... ;. ¦, >:.!•¦
Trustee
(Print or type title of person signing)
Sigiiod/aiid swom to before me mi (date). "'f).0ty' I ^ / ojO]
at L-^liSL- County, C_^. (state). ¦ :' '' '
i)o&@jrfP Nolan' Public: ' >^^-^«*^v^w.-^^i^^W;^
~' Tl|99|¦ ¦ 1 ¦ 'OFFICIALSEAL ;.'•"
. . -n 'f A ) -i i NADA POPOVIC
Commission expires; / / *7 III • | NOTARY PUBLIC, STATE OP ILLINOIS
/ ' :.f: .My Commission Expires 07/09/2017 i
Page 12 of 13 ' '^-^™™v^W(V._^
CTTY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to hi- completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. U 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 Patty" 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 ofthc 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 rarty" means (1) all executive officers of die Disclosing Party listed in Section II.B.I .a., if the Disclosing Party is a corporation; all partners ofthc 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 ofthc 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
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ J Yes f/J.No
If yes, please identify below (1) the name.and title of such person, (2) the name ofthc legal entity to which such person is connected; (3) the name and title ofthc 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 A FFJDAVIT APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix' is (o he cohiplefcd only by (u) the Applicant, and (b) any Icynl entity which hasn direct ownership interest in tiic Applicant exceeding 7.5 percent (nn "Owner"). It Is not to be completed by nny legal entity which lias only an indirect ownership Interest in the Applicant.
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal GodeV
[ ]Ves tyTNo
If the Applicant is a legal entity publiclytradcd on any exchange, is any officerpr director of rhc.'AppIjcanf identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Mun icipal Code?
[ ]Yes [ ]No "f^] Not Applicable
If yes to (I) or (2) above, please .identifybeiow the.n'amc ofthc person or legal entity identified as n building code scoffiaw or .problem; landlord' and the address ofthc building or buildlngs to Which the pertinent;codc violations apply,
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTHTGATTON MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS widi correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-39B5 N Mllwaukee/4B71-4777 W Irving Park Road
[identify tlie Mutter]. Under penalty of perjury; the person signing below: (1) warrants that
he/she is authorized to execute tin's EDS recertification on behalf of tlie Disclosing Parry, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
arc true, accurate and complete as of the date furnished to the City and continue to be true,
accurate and complete as of the date of this recertification, and (3) reaffirms its
acknowledgments.
E. Thomas Collins, Jr. Irrevocable Children's Trust
dated 04/10/96 on behalf of Lisa Marie
(Print or type legal name of Disclosing Party)
Print or type name of signatory:
Perry Weinstein
Title of signatory:
Trustee
—Signed and swom to before mc on [date] -3 2 • ^ (J
^g^=rjjL_U )fin ~ib_ Notary Public.
OFFICIAL SEAL ANEL MEDINA NOTARY PUDUC. STATE OF ILLINOIS Commission Explros April 14,2017
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: CSD Six Corners LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
\/\ the Applicant
OR
[ ] a legal entity holding a direct or indirect interest in the Applicant. Stale the legal name ofthc
Applicant in which the Disclosing Party holds an interest:
OR
3. [ ] a legal entity with a right of control (sec Section II.13.1.) Slate the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 980 North Michigan, Suite 1280 _____
Chicago, IL 60611
Telephone: (312) 377-9111 Fax. Email: jcolllns@clarkslreet.com
Name of contact person: John Collins
Federal Employer Identification No. (ifyou have one): -
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):
Zoning Amondment for property located at 3911-3985 North Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS? DPP _
If the Matter is a conlract being handled by the City's Department of Procurement Services, please complete the following:
Specification // _ and Contract //
Page 1 of 13
SECTION I) -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OI; THE DISCLOSING PARTY I. Indicate (he nature of Lite Disclosing Party
Person
Publicly registered business corporation Privately held business corporation Sole proprietorship
Limited liability company Limited liability partnership Joint venture
N o t - f o r - p r o fi t c o r p o r a 1. i o 11
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 {/j N/A.
B. IE 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 arc legal entities. If there arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal titlchoider(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 CSD Six Comers Member LLC 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% ofthc Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
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 2-1 54-030 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
CSD Six Corners Member LLC 980 N. Michigan Avenue, #1280, Chicago, IL 60611 50% Bixby Bridge Fund II LLC 50%
SECTION HI -- 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 \/\ No
If yes, please identify below the name(s) of such City elected official(s) and describe such rclationship(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 lees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who arc 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.
Page 3 of 13
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. Kevin Wolfberg, Attorney, Schain Banks, 70 W Madison Suite 5300 Estimated 525,000
Chicago. IL 60602
(Add sheets if necessary)
[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under 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 f/j No f ] No person directly or indirectly owns 10% or more ofthc
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
FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article l")(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 Parly 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 1 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.
Page 4 of 13
2. The Disclosing Party and, if the Disclosing Parly is a legal entity, all of those persons or entities
enlificd in Section If.B.l. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have, not, within a five-year period preceding the date of litis 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 properly;
arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, stale or local) with committing any ofthc offenses set forth in clause B.2.b. of this Section V;
have not, within a live-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
c. 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" (nteaning 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 cotvtrols 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 Parly, 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 Ihc 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 cither 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:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthc City, the State of Illinois, or any agency ofthc federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among biddcrs or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither tlie 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.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of thc 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 ofthc U.S. Department of Commerce of their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
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) ofthc Municipal Code.
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
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 lo the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of ail current employees ofthc Disclosing Party who were, at any lime during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthc City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best ofthc Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available ro City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthc City recipient.
N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is \/\ is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
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. Wc 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. Wc 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):
Page 7 of 1.3
If the letters "NA,". the word "None," or no response appears on the lines above, it will bo conclusively presumed that the Disclosing Parly certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms thai arc defined in Chapter 2-1 56 of the Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 of the Municipal Code: Docs any official or employee ofthc City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[]Ycs 1/1 No
NOTE: Ifyou checked "Yes" to Item D.l., proceed to Hems D.2. and D.3. Ifyou checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property 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 ofthc City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power docs not constitute a financial interest within the meaning of litis Part D.
Docs the Matter involve a City Property Sale?
[ ] Yes I/] No
Ifyou checked "Yes" to Item D.l., provide the names and business addresses ofthc 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 cither 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
Page 8 of 13
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
_f 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 I above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: 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"Mailer: (Add sheets if necessary):
(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 die 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.
Page 9 of 13
The Disclosing I1 arty will sub-mil 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.
The Disclosing Party certifies that cither: (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) ofthc Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
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.
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:
Have you developed and do you have on file affirmative action programs pursuant to applicable, federal regulations? (See 41 CFR Part 60-2.)
[]Yes []No
Have you filed with tlie Joint Reporting Committee, the Director ofthc Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission alt reports due under the applicable filing requirements?
[ ] Yes [ ] No
Have you participated in any previous contracts or subcontracts subject lo the equal opportunity clause?
[ J Yes ' [ ] No
Ifyou checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
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.
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.cityofchicaKQ.orR/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
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.
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 Cily in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event, of changes, the Disclosing Parly 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 2-1 54-020 ofthc Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
F.l. Die Disclosing Party is not delinquent in the payment of any lax administered by (he Illinois Department of Revenue, nor are the Disclosing Party or ils Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the Cily. This' includes, but is not limited lo, all water charges, sewer charges, license fees, parking tickets, properly taxes or sales taxes.
F.2 If the Disclosing Parly is the Applicant, the Disclosing Parly 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 (o be hired in connection with the Matter certifications equal in form and substance lo those in F.l. and F.2. above and will not, without the prior written consent ofthc Cily, use any such contractor/subcontractor that docs not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
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 E)isclosing 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 date furnished to the Cily.
CSD Six Corners, LLC
(Sign here)
(Print or type name of person signing)
Manager of CSD Six Corners Member LLC
(Print or type title of person signing)
Signed and sworn to before me on (d
"•¦_jCc^jCL- County, „XlL,
Notary Public.
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMEN T HEADS
Tin'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 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 Patty or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if. as of the date this 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 H.B. 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 Patty 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 I/) No
If yes, please identify below (1) the name and title of such person, (2) the name ofthc 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 I 3 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT ANT) AFFIDAVIT APPENDIX Ii
BUILDING CODE SCOFFLAW/FROBLEM LANDLORD CERTIFICATION
This Appendix is to he completed only by (a) the Applicant, and (b) any legal entity which has n direct 'ownership Interest in the Applicant cxcccdlug.7.S percent (nn "Owner"). It Is not to be completed by any legal entity which has only an Indirect ownership interest in the Applicant.
Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Sectloiv2-92-416 of the Municipal Code?
[ ]Yes (VfNo
If the Applicant is a legal entity publicly traded on any exchange, is any officer.or director of the Applicant identified as a.building 'codc scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Yes [ ]No ^J] Not Applicable
If yes tO;(I) or (2) above,.please identify below the name of the person or legal entity •identified as a building code scofflaw or problem landlord and theaddress ofthc building or buildings to which the.pcrtinent code violations upply,
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you 10 recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTHTCATION
Generally, for use with City Council matters. Not for City procurements unless requested.
'litis rccertification is being submitted in connection with 3911-3985 N Milwaukee/4871-4777 W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that
he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
arc true, accurate and complete as ofthc date furnished to the City and continue lo be true,
accurate and complete as ofthc date of this rccertification, and (3) reaffirms its
acknowledgments.
CSD Six Corners, LLC
(Print or type legal name of Disclosing Party) By:
(sign here) Print or type name of signatory:
Richard Hulina
Title of signatory:
Manager
Signed and sworn to before mc on [dale] 2)22! IL , by
A^AVVoV.rN/V , at __Q^£UC County' —33 tsla,c]-
/ A '"//> ^/t...>, Notary Public.
—-"1
Commission expires:^ iq/,.3 . j
NOTARY PUBLIC. STATE OF ILLINOIS My Commission Expires April 14,2017 '
v *y V v*o> m v *tr^p-*v>-nr v o
Vcr. U-0MI5
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: Blxby Bridge Fund II, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[•] the.Applicant
OR
\j\ a legal entity holding a direct or indited interest in the Applicant. State the legal name ofthc
Applicant in which the Disclosing Party holds an interest: CSD Six Comers LLC
OR ....
3. [ ] a legal entity with a right of control (sec Section II.B.l.)-.State the legal namc of the entity in .
which the Disclosing Party holds a right of control:
D. Business address ofthc Disclosing Parly: 555 Skokie Blvd. Suite 555
NorlhbrookJL 60062 •¦ - ¦ ¦
Telephone: (847)313-6454 ! Fax: (047)498-7893 Email: mbattin@ebixby.com
' Name of contact person: 'Michael"Battln '-¦'«;•
Federal Employer.Identification No. (ifyou have one): __ - - ;„
F; Brief description of contract.trahsaction or other undcr,iaking(referred'-to below as the "Matter") to., which this EDS pertains. (Include project number and locafiph^of prop'crty, if applicable): Zoning Amondmont for property located at 3911-3985 North Milwaukee Avenue; 4671-4777 West Irving Park Road
G. Which City agency or department is requesting this EDS? PPD .
If the Matter is a contract being handled by ihc City's Department of Procurement Services, please complete the following:
Specification it ._. __.and Contract //. . .• • - ... - -¦ ¦ ¦ .
Page I of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF Till- DISCLOSING PARTY
Indicate die nature of ihc Disclosing Ps ] Person
] Publicly registered business corporation ] Privately held business corporation ] Sole proprietorship ] General partnership ] Limited partnership ] Trust
For legal entities, the state (or foreign c Illinois
[X] Limited liability-company
[ ] Limited liability partnership
[ ] Joinl venture
[ ] Not-for-profit corporation
(Is the not-for-profit corporation also n 501(c)(3))'?
( ) Yes [ ] No
f ] Other (plcascspecify)
mtry) of incorporation or organization, if applicable;
3. For legal entities not organized in the State of Illinois: Mas the organization registered lb do business in 'the'-State of Illinois as a foreign entity?
[ ] Yes f ] No [X] N/A
B. IF THE DISCLOSING PARTY ISvAiLEGALENTITY:
I. List below thcTull namcs and titles of all executive, officers, and all directors of the entity. NOTE: For rioFfbr-pfofil corporatioiis, also list below'all'membe'rs, if any, which arc legal entities. If there are no such members, write "no members." For trusts, estates or .other similar entities, list below the legal titlcholdcr(s).
If the entity is a general partncrship.diinitcd partnership, limited liability company, limited liability partnership or joint venture;' list beibw-thc'nhmc and'titlc^of, eacliigeherai partner, maVa^ing-ine'mbcr,' manager or any other pcrsomqr entity thai controls the day-to-day'management of the Disclosing.Party, NOTE: Each legal entity listed below thust s^ '
Name Title David D. Colburn 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,
Page 2 of 13
imcrcsi 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 Cily may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in (he
Disclosing Party
Blackfriars Corp 555 Skokie Blvd., Northbrook, IL 70%
SECTION III -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthc Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[] Yes '' fXj No
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 RE TAINED PARTIES
The Disclosing Party must disclose the name and business address of cacli'''subcontractor,' attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Parly has retained or expects to retain in .connection with the Matter, as well as the nature of the relationship, and'tlic 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'-'-'mcan's ahypersbh or entity who undertakes to influence any lcgislativc''bf^administrative
action on-behalfof any person .o« not-for-profit cntity,foiV an; unpairJ basis,:6r (2)
himself. "Lobbyisf'also means any person or entity any part of whose duties as an employee of
another includes uridcrfakihg''toMnfluchc'e'any legislative or adnu^ ' »¦-¦¦.¦.¦¦¦•
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 tlie disclosure.'
Page 3 of 13
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)
tX) Check here if the Disclosing Parly 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 thc Disclosing;'Party-been declared.in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes :$?\No No person directly or indirectly owns 10% or more ofthc
* 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? ., ,£. ¦. ;1> ,<¦.< i,
W$£*^ iO:No ... . . .'' ^ '" [,,;Vr.-' VZ^J'JS,'^',^ , .' '.'
B. FURTHER CERTIFICATIONS ,.,=;••.-!•' v. ,
.L,; ,Pur.su>iif to,Municjpal.Code Chapter 1 -23,, A.rlic|c;I.("Article^.(whjch,thc Appficant _shouId
coitsuit;,fq'r^ business") andi, 1 cgal;rcquircnicnts),: if ilhc/Disclbsing.Rarty . ,
siibmitdngTh.is';ED and is.dping business with .the.City,- lncnthc.piscjp,sjn .Party
certifies as follows: (i) neither the Applicant nor Hny.^c.o.ntrolling.person is currcnt.ly.jndicied:or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense inyolving;nctiial, attempted, or conspiracy to .comniit bribery,; theft,Traud, forgery, perjury, dishonesty.or.deceit agtiinst an officer or employee.o'f tlfe.City oi' any;sisterjagcncy; and (ii)-the Applicant understands and acknowledges that compliance with Article l 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 live-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
The Disclosing 1'nrly and. if ihe Disclosing Party is a legal cmily, all of those persons or entities identified in Section 11.13.1. of this HDS:
' «: are not presently .debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or hud a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing n public (federal, state or local) transaction or contract under a public transaction; a violation of federal or slate antitrust.statutes; fraud: embezzlement: theft; forgery: bribery: falsification or destruction of records: making false statements; or receiving stolen.property;
arc not presently indicted for, or criminally or civilly charged by, a governmental'entity .(federal, slate or local) with committing any ofthc offenses set forth in clause B.2.b. of this Sect ion V;
have not, within a five-year period preceding ihc.dale.of this EDS, had onc.or more public transactions (federal, slate or local) terminated for cause or default; and ,
have not, within a five-year,period preceding the date of.ihis.EDS, been conyicted,;adjudgcd guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions
: concerning environmental violations,.instituted by ihc City or by.ihc fcdcral.gov.ernmcnt, any statCj or any other unit of local government. .
The certifications in subpartsi3;,4.and.5 concern: ; ;-
the Disclosing Party;
any '>Cohtrac,tor" (meaning any«co.ntractbr or s.ubc;ohl.ractoriisc.d;by thc.pisclpsing^Party in .
connection!with-the Matter, including but hoi limited to, ail persons or legal cntitic%s:di,s.clpsc-;under-,
Section IV, -'Disclosure of Subcontractors.and Other. Retained Parlies"); ' J.
any "Affiliated Entity" (meaning>^ers.on:or••cn.tity.•thal,^directly•.or indirectly: cpntrpls the Disclosing Party, is controlled by thc Disclosing Party, of is, with the Disclosing Party, under .-common control of another person or entity. Indicia of conlrpl include, without limitation:
' interlocking management among family members^
and equipmehlj common use of cnipioyces^prUjrganizati.on^ ¦¦;;
ineligibility .of a business entity to do business with federal or state or local government, ;ih,cluding . the City, using substantially the same management, ownership, or principals as the ineligible eniityj; with respect to Contractors, the term Affiliated Entity.mcans:a.person or entity that (Erectly 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.thc Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthc 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 Parly 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 fin lily, 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:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe', a public officer of employee of the Cily, the Slatc^of Illinois, or any agency of the federal government of of any state or local government in the United Statesof America,'iirthat officer's or-employee's' official -capacity: '•
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
'prospective bidders, in restraint of freedom of competition'-by agreement to bid a fixed-price or otherwise; or
made an'admission of such conduct described in a. or b; above .that 'is 'a - matter -d f record, bin
have not been prosecuted for such conduct; or • ., .
' violatedi'iiie.;'prp\dsio'ns;of'Mitnicipal-Codc Section 2-92-610 (Living Wage Ordinance).
4. : "Neither the-Disclbsing-Tarty, Affiliated-Entity or Cohtracfori-orvahy Of their cniployccs,- 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 stale or of thc United Stales of'!
America that contains the some elements as the offense of bid-rigging or bid-rotating.
5, Ncithcr'tbcTjiscl^ Affiliated EntityjSilisted^pri anyrof the follo>yirig;listS:.
maihtamcd;by?^ of rtic"u.;S/:De^^
Bureau.of.Industjy;and;Se.cunty'p^ ofCpmriicfce'bW
pcsignate.djNa'tidnfil's^
Debarrcd'List. ' '¦^•^¦'•'^r^V :;: v- ¦ ¦•¦ ¦;: ;.; ^;:>i\k.^-sA>:^ 'i V;;./<, -- -
v"'6'.'';'''T:lfc-Discl6siiig''-'P.afty^un'dcrstands' and shall comply with the applicable rcquircnicnts-of Chapters 2-55 (Legislative Ins'pccior'Geh'erai). 2-56 (Inspector General) aiid 2-1 56 (Govcrhmen.tal;iEtliics)-of:thc MuiiicipalCodc. '¦'''
7. If tlie Disclosing Party is Tillable to certify to any ofthc abovcsiatements in this; Part ,-13 ¦•(¦Further
Certifications), the Disclosing Party niust explain below: • •«•••; •;
Page 6 of 13
If the letters "NA," the word" "None," oj no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any tiipc during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official,
ofthc City of Chicago (if none, indicate with "N/A" or "none"). None
9. To the best of ihc Disclosing Party's knowledge after reasonable inquiry, the following is a complete lisi of all gifts thai the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of ibis EDS, lo an employee, or elected or appointed official, of ihc City of Chicago, For purposes of this statement, a "gift" docs not include: (i) anything made generally available to Cily employees or to ihc general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
None
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Parly certifies that the Disclosing Party (check one)
[ ] is Ik.] is not
a "financial institution" as defined in Section 2-32-455(b) of ihc Municipal Code.
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 predntory lender as defined in Chapter 2-32 ofthc Municipal Code. Wc 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 ihe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
Page 7 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 Parly certified to ihe above statements.
D. CERTIFICATION -REGARDING INTEREST IN CITY. BUSINESS
Any words or terms that are defined in Chapter 2-156 of Ihc Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 ofthc Municipal Code: Docs any official or employee of the City hav,c ,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. 1., proceed to Items D.l and D.3. If you:'chccked"No"'to
item.b. 1 proceed to Part.E. ' -
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no Cily 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) bclongs to the City, or. (ii) is sold for faxes or assessments, or (iii) is sold by virtue of legal process at the suit of thc'City (collectively, "City Property Sale"). Compcnsation.fpr property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Property Sale?
[ ] Yes pq No
Ifyou checked "Yes" to Item D.l., provide the ''names' and business addressesi of thc'City officials or employees hayjng:Siich -interest .andjidentiry the nature of such interest:
Name Business Address Nature of Interest
——--——rt-——-r-'-'r-'-y.-: -~.-^rjV :, iv.'. ¦-!¦:¦ ;; :'. ¦-'—:',: ,v.,.V>--..i.-'•:~^'~r~~ —
4. The. Disclosing-PartyTurthcr certifies that.no prohibited financial interest in th.c-Maticr 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 Parly checks 2., the Disclosing Party must disclose below or in an attachment to this EDS nil information required by paragraph 2. Failure to
Page 8 of 13
comply with these disclosure rcquiicmcnts may make any contract entered into with the City in connection with the Matter voidable by the City.
X I. The Disclosing Party verifies that the Disclosing Parly has searched any and all records of ihc Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery eta (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of ilhcir.slavcs), and the Disclosing:Parly.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 shivery or slaveholder.insurance policies. The.pisclosing P.arly.vcrifics that the following constitutes full disclosure of all such . . rccords. including .the names of any and.all slaves or slavcholdcrs described, in :lhosc records:
SECTION VI *CERtlFl!tXfr6.NS'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 arc 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 m ade lobbying contacts on behalf of the Disclosing Party with respect to the"Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "N A" or if ihe 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:acrivitics or lo pay any person or entity lo influence or attcnipt to jnfluence on officer or cmployee 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 inio any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
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.
The Disclosing Patty 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 nn organization described in section 501(c)(4) ofthc Internal Revenue Code of 1986 but has not engaged and will not engage in ''Lobbying Activities".
If the Disclosing Parly is the Applicant, the .Disclosing Party must obtain certification's equal in form and substance to paragraphs A.l. through A.4. above from albsubconiractors bcfore 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 ihc City upon request.
13. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations requirethc.Applicant and.:all,proposed
subcontractors to submit the following information with their bids'or in writing at the ouisct of
negotiations, .. .... ,, , ¦¦ ¦.
Is the Disclosing Party the Applicant? ...
[ ] Yes []No - . . , ¦ , .
If "Yes," answ.crjhc three questions, below:.
Have you' developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Pari 60-2.) , . " ;
[J'Yes (] No
Have you filed with the Joint Reporting Committee, the Director ofthc Office of Federal
Contract .'Compliance Programs, or the Equal :lmiploymcnt Opportiihity Commission all reports due
under the applicable filing requirements? ¦"'•'¦' ¦ ' ' ''¦'"' ""' V'
!ycs ; " !';'' [ i No ; - • '¦'::':;;' •"¦!'v"''^':;;;''"'Z'V".' '
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
'Ycs "' [ ] No :
Ifyou checked "No"' to question I. or 2. above, please provide aivcxplanatidn':
Page 10 of T 3
SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Parly understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the Cily in connection.with the Matter, .whether, procurement, Cily assistance, or-other City action, and are material inducements to ihc City's execution of any contract or taking other action with respect to the Matter. The Disclosing Parly understands that it musl comply with all statutes.-ordinances, and regulations on which this EDS is based. ,
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164,of the Municipal Code, impose certain duties and obligalions;on persons or entities seeking City contracts, work, business, or transactions. Thc'full text of these ordinances and.a training program is available on line at www.citvofchicni'O.oi u/l.'ithics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660 Thc-Disclosing Party must complyTully, with the applicable ordinances.
..... *., /. .
If the Cily determines that any information provided in this EDS is false, incomplete or inaccurate, any contractor other agreemohl-in-counection wiih which -it-.is submitted may be rescinded,or;b.c,;,vpidupr voidable, and the CTty nVay pursue any'remcdies under the.conlracl.qr agreement (if not. r.csciridc.diqr , . void), at law, or in cquily.-'iricliiding'tcrminaling theiDisclpsing'Parly's.participation: m
declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at .
law for a false statement of material fnct may include incarceration and an award lo the City of treble
damages. - ;
It is the City's policy to make this document available to the public on its Internet-site jiu^/or-upon request. Some or all of the information provided on this EDS and any attachments;^;!^
made available to the public on the Internet, in response to a Freedom of Information Actfr'c^u^st} or otherwise. By completing and signing this EDS, the Disclosing Parly waives and releases any possible rights or claims which it may have against the City in connection with the public reJeasc-^f%XP,ffllM!j?n ' contained in this EDS and also authorizes the City to verify the accuracy of any information submitted, in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the .Disclosing Party musl supplement this EDS up to the time the Cily takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Parly must update this EDS as the contract requires. -NOTE: With respect to Matters subject to Article l.of , . Chapter 1-23 ofthc Municipal Code (imposing PERMX'NEN
offenses), the .infornvalipn.pro.yidcd,hcrcin.regarding.eligibility must be kept current for a longer-period,,
as required by Chapter ?1 -23;and Section 2-1 54-020 of the Municipal Code: ,. ....
The Disclosing Party-represents and warrants that:
Page 11 of 13
FT. Tlie Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor arc the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to ihc Cily. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F;2 Ifthc Disclosing Party is the Applicant, (he Disclosing Party and its Affiliated Entities will not usc,"nof permit their subcontractors to use, any facility listed by the U\S. E,P:A.1on:thc federal Excluded Parties -List System ("EPLS") maintained by ihc U. S. General Services .Administration.
F.3 If the Disclosing Party.is the Applicant, the Disclosing-Paily will obtaiivfrom Imy ¦ ... contractors/subcontractors hired or to be hired in connection wilh the Matter certifications equal in fdrm-and-substancc to those in F.l. and F.2. above and will,not; without th'c'pnqr:vwr CityVusc any-such contractor/subcontractor thai-docs not provide such;ccrlifici»'tipns or thai the:. Disclosing Party has reason to believe has not provided or cannot provide .truthful certifications.
NOT E: Ifthc Disclosing Party cannot certify as to any of the items in F-l ,,T'.2. or F.3. above, an
explanatory statement must be: attached lo litis EDS. ' ¦¦: .;
CERTIFICATION
Uridcfi.pchally-of pe^
this~*EliS^arid^ on b'cBajf-of-the-pjselosin^
e'efti fixations' and:stYicrii^ accurate
and^cbmplete as ofthc date furnished to the City. v ••• j:':. ./.
Bixby Bridgc.Fund II, LLC _
(Print or type name of Disclosing Pany)
•: (Sign here) ¦ '' ¦¦¦ ¦ ^ : A v1,-?;/-;. ¦;' •¦:
;P.avi.d;p'Colburn :.¦¦ . ^v,,.'^ ^i^v-i^:.
(PHhUoV'typc name of. pet son sighing) ' ¦¦'.¦¦>':' ¦'.¦•'o. .'¦ ¦•
• Manager
(PniiV-brtype titlcVp'fperson'signing)
Sighed and swom to before me on -(date) -/^^^ttl6t.Klif?4'-'^-/-^''' at ;^.6QKi : County, HiU^l\\<^\h- (slate).- :
C ¦¦r^frt&Mxb^,.//^., v/ll?a-^-.__K_-^.- -NotaryPublic, .j-. : :oificial.seal
j (1 ' ' A KIMBERLY M BANKS
. / •?-,„,, v Notary Public - State o( Illinois
Commission expires: It-13--w—— » ¦* M V "u-
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is lo be .completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. II 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 Parly nuist 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 ofthc 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 us 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 (I) all executive officers of the Disclosing Party listed in Section II.D.l .a., ifthc Disclosing Party is a corporation; all partners ofthc Disclosing Party, if the Disclosing Party is a general partnership; all general partners nnd 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 bfficers" 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 DiscIosing.Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently lmve a "familial relationship" with an elected city official or department head?
[ ] Yes . (X.] No
If yes, please identify below (1) thenamcand titlcofsuch person, (2) the name ofthc legal entity to which such person is connected; (3) the name and title ofthc elected city official or department head lo 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 APPENDIX U
BUILDING CODE SCOFFLAW/PRORLEM LANDLORD CERTIFICATION
Tills Appendix is to he completed only by (n) the Applicant, and (b) any legnl entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only au indirect ownership Interest in the Applicant.
Pursuant to Municipal Code Section 2-154-0IO, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuunt to Section 2-92-416 ofthc Municipal Code? .
[ ]Yes NxfNo
Ifthc Applicant Is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Yes [ ]No ^7] Not Applicable
3. If yes to (I) or (2) above, please identify below the name ofthc person or legal entity
identified as a building code scofflaw or problem landlord and the address ofthc building or buildings to which tlie pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF.THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This rccertification is being submitted in connection with 3911-3985'N Milwaukee/4671 ^4777 W Irving Park Road
[identify the Matter]. Under penalty of perjury, the person signing below; (!) warrants that
he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as ofthc date furnished to the City and continue to be true,
accurate and complete as of the date of this recertification, and (3) reaffirms its
acknowledgments.
Bixby Bridge Fund II. LLC Date: ^ckk2^M^2t2°1 ^
(Print or type legal name of Disclosing Party) "
(sign here)
Print or type name of signatory:
David D. Coblurn
Title of signatory:
Manager.
County, "37f/f's\6t.S [state].
Signed and swom to before me on [date] faJjQu4/?sy " . by
iWrl 0. Colburn . at G>ak
Notary Public.
Commission expires: fycn&tx&cn-, $0/. Y
Vci. 11-01-05
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