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ORDINANCE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1: Title 17 of the Municipal Code of Chicago, Chicago Zoning Ordinance, is amended by changing all the B3-3 Community Shopping District and RM5 Residential Multi-Unit District symbols and indications as shown on Map No. 3-F in the area bounded by:
West Schiller Street;
a line 110.2 feet east of and parallel to North Sedgwick Street; a line 116 feet south of and parallel to West Schiller Street; a line 134.6 feet east of and parallel to North Sedgwick Street; a line 141 feet south of and parallel to West Schiller Street; the public alley next east of and parallel to North Sedgwick Street; a line 166 feet south of and parallel to West Schiller Street; and North Sedgwick Street;
to those of B3-5 Community Shopping District, which is hereby established in the area above described.
SECTION 2: Title 17 of the Municipal Code of Chicago, Chicago Zoning Ordinance, is amended by changing all the B3-5 Community Shopping District symbols and indications as shown on Map No. 3-F in the area bounded by:
West Schiller Street;
a line 110.2 feet east of and parallel to North Sedgwick Street; a line 116 feet south of and parallel to West Schiller Street; a line 134.6 feet east of and parallel to North Sedgwick Street; a line 141 feet south of and parallel to West Schiller Street; the public alley next east of and parallel to North Sedgwick Street; a line 166 feet south of and parallel to West Schiller Street; and North Sedgwick Street;
to those of Residential-Business Planned Development No. , which is hereby
established in the area above described, subject to such use and bulk regulations as are set forth in the Plan of Development herewith attached and made a part hereof and to no others.
SECTION 3: This ordinance shall take effect upon its passage and due publication.
Common Address(es): 335-345 West Schiller Street; 1355-1369 North Sedgwick Street
Residential-Business Planned Development No. Bulk Regulations and Data Table
19,559 sq.ft. (0.449 acres)
8,530 sq. ft. (0.196 acres ) 28,089 sq. ft. ( 0.645 acres )
4.50
98 dwelling units 24 parking spaces
1 berth(s) (10'x25') 101 feet, 0 inches
Minimum Setbacks from Property Lines:
North: East: South: West:
0 feet Per attached site plans 0 feet 0 feet
APPLICANT: 335 Schiller LLC
ADDRESS: 335-345 West Schiller Street; 1355-1369 North Sedgwick Street
INTRODUCTION DATE: October 11, 2017
REVISED / CPC DATE:
*
Residential-Business Planned Development No.
PLANNED DEVELOPMENT STATEMENTS
The area delineated herein as Residential-Business Planned Development Number 66, as amended ("Planned Development"), consists of approximately 19,559 net square feet (0.449 acres) of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Property") and is owned or controlled by 335 Schiller 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, assign or grantees.
Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Planned Development.
Ingress or egress shall be pursuant to the Planned Development 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
APPLICANT: 335 Schiller LLC
ADDRESS: 335-345 West Schiller
INTRODUCTION DATE: October 11, 2017
REVISED / CPC DATE:
Street; 1355-1369 North Sedgwick Street
Page I of 5
issuance of any Part II approval, the submitted plans must be approved by the Department of Transportation.
This Plan of Development consists of these 17 Statements and the following:
Bulk Regulations and Data Table Existing Zoning Map General Land-Use Map
Planned Development Boundary and Property Line Map Site Plan Landscape Plan
Building Elevation (East Building Elevation) Building Elevation (South Building Elevation) Building Elevation (West Building Elevation) Building Elevation (North Building Elevation)
prepared by Brininstool + Lynch, Ltd. and dated October 11, 2017, submitted herein.
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 Chicago 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 Chicago Zoning Ordinance, this Planned Development shall control.
The following uses shall be permitted in this Planned Development:
Dwelling Units located above the ground floor; Cultural Exhibits and Libraries, Day Care; Postal Service; Business Support Services; Communication Service Establishments; Eating and Drinking Establishments (all); Financial Services (excepting Payday/Title Secured Loan Stores and Pawn Shops; Food and Beverage Retail Sales (excepting Liquor Stores (packaged goods; Medical Service; Office; Personal Service (all); Repair or Laundry Service; Retail Sales (General); Residential Support Services; and related, incidental and accessory uses including but not limited to accessory parking.
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. Off-Premise signs are prohibited within the boundary of the Planned Development.
APPLICANT: 335 Schiller LLC
ADDRESS: 335-345 West Schiller Street; 1355-1369 North Sedgwick Street
INTRODUCTION DATE: October 11, 2017
REVISED / CPC DATE:
Page 2 of 5
For purposes of height measurement, the definitions in the Chicago 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 Property shall be in accordance with the attached Bulk Regulations and Data Table. For the purpose of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations and Data Table has been determined using a net site area of 19,559 square feet and a base FAR of 4.5.
Upon review and determination, and pursuant to Section 17-13-0610 of the Zoning Ordinance, Part II Review shall be assessed a fee by the Department of Planning and Development. The fee, as determined by staff at the time of its submission, 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, including Section 17-13-0800 of the Zoning Ordinance. 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 Department of Streets and Sanitation, and the Department of Fleet and Facility Management, under Section 13-32-085 of the Municipal Code, or any other provision of the Municipal 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.
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.
APPLICANT: 335 Schiller LLC
ADDRESS: 335-345 West Schiller Street; 1355-1369 North Sedgwick Street
INTRODUCTION DATE: October 11, 2017
REVISED / CPC DATE:
Page 3 of 5
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. The Applicant shall obtain the number of points necessary to meet the requirements of the Chicago Sustainable Development Policy, in effect at the time the Part II review process is initiated for each improvement that is subject to the aforementioned Policy and must provide documentation verifying compliance.
The Applicant acknowledges the city's ongoing and evolving initiatives to enhance awareness of, and support and encourage participation by, Minority and Women's Business Enterprise certified contractors and local city residents. To assist the city in promoting such MBE, WBE and local city resident involvement, the Applicant may provide the Department of Planning and Development with any preliminary outreach plans designed to elicit MBE, WBE and local city resident participation, such submission may include copies of certified letters, and receipts of such, sent to MBE/WBE contractor associations and the ward office of the alderman in which this project is proposed to be located. In conjunction with the Applicant's submission for Part II permit reviews, the Applicant will provide DPD (and upon request, the full Plan Commission) with all responses to any preliminary outreach plans and certified letters, updates on any associated communications or meetings and anticipated percentages of MBE, WBE and local city resident participation. Prior to issuance of their Certificate of Occupancy, the Applicant will provide DPD with actual level of MBE and WBE certified contractor and local city resident participation. All such details will be provided in a form acceptable to the Zoning Administrator or Commissioner of the Department of Planning and Development.
The Applicant acknowledges and agrees that the rezoning of the Property from various underlying zoning districts to uniform underlying zoning district B3-5 Community Shopping District, and then to this Planned Development (PD), triggers the requirements of Section 2-45-115 of the Municipal Code of Chicago (Affordable Requirements Ordinance or ARO). Any developer of a residential housing project within the meaning of the ARO must: (i) set aside 10% of the housing units in the residential housing project (the Required Units) as affordable units, or with the Commissioner of the Department of Planning and Development's (DPD) approval, provide the Required Units in an approved off-site location; (ii) pay a fee in lieu of the development of the Required Units; or, (iii) any combination of (i) and (ii); provided, however, that residential housing projects with 20 or more units must provide at least 25% of the Required Units on-site or off-site. If the developer elects to provide affordable units off-site, the off-site affordable units must be located within a two-mile
APPLICANT: 335 Schiller LLC
ADDRESS: 335-345 West Schiller Street; 1355-1369 North Sedgwick Street
INTRODUCTION DATE: October 11, 2017
REVISED / CPC DATE:
Page 4 of 5
radius from the residential housing project and in the same or a different higher income area or downtown district. The Property is located in a higher income area, within the meaning of the ARO, and the project has a total of 98 units. As a result, the Applicant's affordable housing obligation is 10 affordable units (10% of 98), 2 of which are Required Units (25% of 10, rounded down). Applicant has agreed to satisfy its affordable housing obligation by making a cash payment to the Affordable Housing Opportunity Fund in the amount of $125,000 ($100,000, if providing units on-site to CHA) per unit (Cash Payment) and/or providing 2 affordable units in the rental/for sale building to be constructed in the PD and/or 8 affordable units in an off-site building located at TBD and/or entering into an agreement with the Chicago Housing Authority (CHA) to provide affordable units in the PD, as set forth in the Affordable Housing Profile Form attached hereto as Exhibit A. The Applicant agrees that the affordable rental/for sale units must be affordable to households earning no more than 100% of the Chicago Primary Metropolitan Statistical Area Median Income (AMI), as updated annually by the City of Chicago. If the Applicant subsequently reduces (or increases) the number of housing units in the PD, the Applicant shall update and resubmit the Affordable Housing Profile Form to DPD for review and approval; DPD may adjust the number of required Affordable Units without amending the PD. Prior to the issuance of any building permits for any residential building in the PD, including, without limitation, excavation or foundation permits, the Applicant must make the required Cash Payment and/or execute and record an affordable housing agreement in accordance with Section 2-45-115(L). The terms of the affordable housing agreement and any amendments thereto are incorporated herein by this reference. The Applicant acknowledges and agrees that the affordable housing agreement will be recorded against the PD, or the applicable portion thereof, and will constitute a lien against such property. The Commissioner of DPD may enforce remedies for any breach of this Statement 16, including any breach of any affordable housing agreement, and enter into settlement agreements with respect to any such breach, subject to the approval of the Corporation Counsel, without amending the PD.
17. This Planned Development shall be governed by Section 17-13-0612. 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 the pre-existing B3-5 Community Shopping District.
APPLICANT: 335 Schiller LLC
ADDRESS: 335-345 West Schiller Street; 1355-1369 North Sedgwick Street
INTRODUCTION DATE: October 11, 2017
REVISED / CPC DATE:
Page 5 of 5
Legend
Property Line
EXISTING ZONING MAP
Applicant: 355 Schiller LLC Scale: NTS
AddreSS: 335-345 West Schiller Street / 1355 - 1369 North Sedgwick Street
Introduced: October 11, 2017 BRININSTOOL
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Address: 335-3-15 West Schiller Street / 1355- 1369 North Sedgwick Street
Introduced: October 11, 2017 Revised / CPC Date: —
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335 - 345 WEST SCHILLER STREET 1355-1369 NORTH SEDGWICK STREET
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Applicant: 355 Schiller LLC
Address: 335-345 West Schiller Street / 1355- 1369 North Sedgwick Street
Introduced October 11, 2017 Revised / CPC Date: -
PLANNED DEVELOPMENT BOUNDARY AND PROPERTY LINE Scale. 1" = 50'-0"
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Applicant: 355 Schiller LLC
Address: 335-345 West Schiller Street/ 1355- 1369 North Sedgwick Street
Introduced: October 11, 2017 Revised / CPC Date: —
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TOTAL GREENROOF: 5974 SF
PROPOSED NEWTREE SPECIES ARE AS FOLLOWS: ALTERNATING SHAWNEE BRAVE, AMERICAN SENTRY LINDEN, NORTHERN CATALPA, REGAL PRINCE, PRAIRIE SENTINEL.
TREE GRATES MUST BE STAMPED WITH THE "CITY OF CHICAGO" WITH AN OPENING OF 24'.' 5/8" BLOCK LETTERING AROUNDTHE PERIMETER OF EACH GRATE PANEL WILL SUFFICE. SECURING BOLTS MUST BE USED BENEATH EACH GRATE TO CONNECT EACH GRATE HALF TOGETHER.
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Applicant: 355 Schiller LLC
Address: 335-345 West Schiller Street /1355 -1369 North Sedgwick Street
Introduced: October 11, 2017 Revised / CPC Date- —
METAL SIDING SYSTEM
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Applicant: 355 Schiller LLC Scale; 1' = 25'"0'
Address: 335-345 West Schiller Street / 1355 - 1369 North Sedgwick Street
Introduced- October 11, 2017 BRININSTOOL
Revised / CPC Date: — + LYNCH|109|© Bnninstool + Lynch, Ltd
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Applicant: 355 Schiller LLC Scale: 1 = 25 "°
Address: 335-315 West Schiller Street /1355 -1369 North Sedgwick Street
Introduced: October 11, 2017 BRININSTOOL
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Applicant: 355 Schiller LLC Scale: 1" =25'-°"
Address: 335-345 West Schiller Street / 1355 - 1369 North Sedgwick Street
Introduced: October 11, 2017 BRININSTOOL
Revised / CPC Date-— + LYNCH|109|© Bnninstool + Lynch, Ltd.
METAL SIDING SYSTEM
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Applicant: 355 Schiller LLC Scale 1" = 25 "°"
Address: 335-345 West Schrller Street / 1355 - 1369 North Sedgwick Street
Introduced: October 11, 2017 BRININSTOOL
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DALEY & GEORGES
Law Offices
October 10, 2017
Chairman, Committee on Zoning City Hall - Room 304 121 N. LaSalle St. Chicago, Illinois 60602
Re: 335-345 West Schiller Street; 1355-1369 North Sedgwick Street Application for Zoning Map Amendment (Planned Development)
The undersigned, Richard A. Toth, being first duly sworn on oath, deposes and states the following:
The undersigned certifies that he has complied with the requirements of § 17-13-0107 of the Chicago Zoning Ordinance by sending the attached letter to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot lines of the subject property, exclusive of public roads, streets, alleys and other public ways. The attached letter was sent by USPS first class mail, no more than 30 days before filing the application.
The undersigned certifies that the notice contained: the address(es) of the property that is the subject of the application; a statement of the intended use of the property; the name and address of the applicant; the name and address of the owner; and a statement that the applicant intends to file an application for a change in zoning on approximately October 10, 2017.
Richard A. Toth
The undersigned certifies that he has made a bona fide effort to determine the names and last known addresses of the persons to be notified under § 17-13-0107 of the Chicago Zoning Ordinance by obtaining ownership information from the most recent authentic tax records of Cook County, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subjectsitejsa complete list containing the names and addresses of the people required to be served.
"•-"''' ¦¦¦¦i OFFICIAL SEAL LAUREN EAVES NOTARY PUBLIC • STATE OF ILLINOIS HfCummkn Expnt J*nu*ry 27,2021
1596.0000
Subscribed and sworn to before me this October 10, 2017
312 726-8797
daleygeorges.com 20 S. Clark St., Suite 400 Chicago, IL 60603-1835
DALEY & GEORGES
Law Offices
October 10, 2017
Re: 335-345 West Schiller Street; 1355-1369 North Sedgwick Street Application for Zoning Map Amendment (Planned Development)
Dear Property Owner:
In accordance with the requirements of the Chicago Zoning Ordinance for a Zoning Map Amendment, specifically Section 17-13-0107, please be informed that on or about October 10, 2017, I, the undersigned attorney, am filing an application on behalf of the Applicant, 335 Schiller LLC, for a change in zoning from B3-3 Community Shopping District and RM5 Residential Multi-Unit District to B3-5 Community Shopping District and then to Residential-Business Planned Development, for the property generally located at 335-345 West Schiller Street; 1355-1369 North Sedgwick Street, Chicago, Illinois.
The Applicant proposes to construct a mixed-use building with first floor commercial (approximately 4,311 sf) and dwelling units on the second and higher floors (98 dwelling units), with an approximate height of 101 feet.
The Applicant and Owner is 335 Schiller LLC, 1907 North Beverly Drive, Beverly Hills, CA 90210.
I am an attorney for the Applicant and can provide additional information on the application. My address is 20 S. Clark St., Suite 400, Chicago, Illinois 60603.
PLEASE NOTE THAT THE APPLICANT IS NOT SEEKING TO PURCHASE OR REZONE YOUR PROPERTY. THE APPLICANT IS REQUIRED BY LAW TO SEND YOU THIS NOTICE BECAUSE YOU OWN PROPERTY LOCATED WITHIN 2 50 FEET OF THE SUBJECT PROPERTY.
Richard A. Toth
1596.0000
Sincerely,
312 726-8797
daleygeorges.com 20 S.Clark St., Suite 400 Chicago, IL 60603-1835
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CITY OF CHICAGO COf . I I ) ^ H
APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE
ADDRESS of the property Applicant is seeking to rezone:
335-345 West Schiller Street: 1355-1369 North Sedgwick Street
Ward Number that property is located in: 27
APPLICANT 335 Schiller LLC
ADDRESS 1907 North Beverly Drive CITY Beverly Hills
STATE CA ZIP CODE 9 0210 PHONE (312) 610-1800
EMAIL gdl@lattaslaw.com CONTACT PERSON George Lattas
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
ADDRESS CITY
STATE ZIP CODE PHONE_
EMAIL CONTACT PERSON
5. If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:
ATTORNEY Mara Georges, Daley and Georges. Ltd.
Richard Toth, Daley and Georges, Ltd.
ADDRESS 20 S. Clark St Suite 400
CITY Chicago STATE _IL ZIP CODE 60603
PHONE (312) 726-8797 FAX (312) 726-8819 EMAIL mgeorgesQdaleygeorges.com
rtothOdaleygeorges.com
1596.0000
6. 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.
Lakshmi Capital Management LLC
Lakshmi Capital All Weather Fund LP
Thanqavel Family 2 006 Irrevocable Trust
Thanqavel Family Trust
On what date did the owner acquire legal title to the subject property? September 2017
Has the present owner previously rezoned this property? If yes, when?
No.
B3-5 and then to
Present Zoning District B3-3 & RM5 Proposed Zoning District Planned Development
Lot size in square feet (or dimensions) 19,559 ef (irregular)
Current Use of the property Vacant land.
Reason for rezoning the property To allow new development as deacrihed in
paragraph 13 below.
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)
A mixed-use building with first floor commercial (approximately 4,311 sf)
and dwelling units on the second and higher floors (98 dwelling units),
approximately 101 feet high with approximately 24 parking spaces.
The Affordable Requrements Ordinance (ARO) requires on-site affordable housing units and/or
a financial contribution for residential housing projects with ten or more units that receive a zoning change which, among other triggers, increases the allowable floor area, or, for existing Planned Developments, increases the number of units (see attached fact sheet or visit www.cityofchicago.org/ARO for more information). Is this project subject to the ARO?
YES x NO
1596.0000
COUNTY OF COOK STATE OF ILLINOIS
Ananthan Thanqavel , 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
335 Schiller LLC
Subscribed and Swom to before me this By. LakBnmi capital Management LLC, its Manager
day of October , 20 17
By: Ananthan Thangavel, its Manager
DOMENICAALBERO Notary Public State of New Yor*
Commission Expires September 3D,«2o«j (
NO.01AL6289669 Qualified in New York County r3D,«
Date of Introduction:.
File Number:
Ward:
1596.0000
335 Schiller LLC 1596.0000 1
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:
335 Schiller LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[x] the Applicant and property owner.
OR
[ ] a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR
[ ] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 1907 n. Beverly Dr.
Beverly Hills, CA 90210
Telephone: (312) 610-1800 Fax: (312) 626-2414 Email: qdi@lattasiaw.com
Name of Contact person: George Lattas
Federal Employer Identification No. (if you have one): To follow.
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Application for zoning map amendment (planned development) for:
335-345 West Schiller Street; 1355-1369 North Sedgwick Street
G. Which City agency Or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # n/a and Contract # n/a
Ver.2017-1 Page 1 of 14
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person [xj
[ ] Publicly registered business corporation [ ]
[ ] Privately held business corporation [ ]
[ ] Sole proprietorship [ ]
[ ] General partnership (Is
[ ] Limited partnership
[ JTrust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation the not-for-profit corporation also a 501(c)(3))?
[ ]Yes [ ]No Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
Illinois.
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[ ] Yes [ ] No [x] Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Lakshmi Capital Management LLC* Manager
*Note; Lakshmi Capital Management LLC is a registered investment advisor with the
Securities and Exchange Commission. A copy of its most recent Form ADV is attached.
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% of the Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
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limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Lakshmi Capital Management LLC See Section I.B. 1. 00%
Lakshmi Capital All Weather Fund LP See Section I.B. 24.03%
Thangavel Family 2006 Irrevocable Trust See Section I.B. 10.47%
Thangavel Family Trust See Section I.B. 64.50%
SECTION III -- INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? [ ] Yes [x]No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? [ ] Yes [x] No
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Not applicable.
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party? [ ]Yes [x]No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
Not applicable.
SECTION IV DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount 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. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Brininstool + Lynch. 1144 W. Washington St. Architect $15,000 estimated
(David Brininstool) Chicago, IL 60607
George Lattas 3660 W. Irving Park, 2nd Fir Attorney $15, 000 estimated
Chicago, IL 60618
Daley and Georges, Ltd. 20 S. Clark St., #400 Attorney $15, 000 estimated
, . (Mara Georges) . Chicago, IL 60603
(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 SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [x] 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 Not applicable.
B. FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
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The Disclosing Party and, if the Disclosing Party is a legal entity, all of those 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, state or local unit of government;
have not, during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 14
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
Page 6 of 14
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. 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:
None.
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.
12. 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 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.
13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
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 MCC Section 2-32-455(b).
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 MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
Page 7 of 14
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
None.
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 FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ]Yes [x]No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ]Yes [x]No
If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
Not applicable.
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. If the Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:
Not applicable.
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. Not applicable - the matter is not federally funded. A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
Not applicable - the matter is not federally funded.
(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, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2017-1 Page 9 of 14
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.
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 Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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. Not applicable - the matter is not federally funded.
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No Not applicable - the matter is not federally funded
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 Not applicable - the matter is not federally funded
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No [ ] Reports not required
Not applicable - the matter is not federally funded
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No Not applicable - the matter is not federally funded
If you checked "No" to question (1) or (2) above, please provide an explanation:
Not applicable.
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SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
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 Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.citvofchicago.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 this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy 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 MCC Chapter 1-23, Article I (imposing PERMANENT INELIGD3ILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
Page 11 of 14
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and Appendices A and B (if applicable), on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and Appendices A and B (if applicable), are true, accurate and complete as of the date furnished to the City.
335 Schiller LLC
(Print or type exact legal name of Disclosing Party) By: Lakshmi Capital Management LLC, its Manager By: Ananthan Thangavel, its Manager
(Sign here)
Ananthan Thangavel
(Print or type name of person signing)
Manager of Lakshmi Capital Management LLC (Print or type title of person signing)
Signed and sworn to before me on (date) October Lp 2017
DOMENICAALBERO
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [x] No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to
which such person is connected; (3) the name and title of the elected city official or department head to
whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Not applicable.
i
Page 13 of 14
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
[ ]Yes [x]No
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 MCC Section 2-92-416?
[ ] Yes [ ] No [x] The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Not applicable.
Page 14 of 14
FORM ADV
UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION AND REPORT BY EXEMPT REPORTING ADVISERS
Primary Business Name: LAKSHMI CAPITAL MANAGEMENT LLC . .¦¦'..'>;¦.¦ ; • / ; ; CRD Number
Annual Amendment - All Sections Rev. 10/2012
4/6/2017 5:38:29 PM V ¦"' ¦>.¦;" >'. ^ Z V - 'V';'"'^' :V.r' -~ ¦" • .': . ¦ V:\.:^.
WARNING: Complete this form truthfully. False statements or omissions may result in denial of your application, revocation of your registration, or criminal prosecution. You must keep this form updated by filing periodic amendments. See Form ADV General Instruction 4.
Item 1 Identifying Information
Responses to this Item tell us who you are, where you are doing business, and how we can contact you.
Your full legal name (if you are a sole proprietor, your last, first, and middle names): LAKSHMI CAPITAL MANAGEMENT LLC
Name under which you primarily conduct your advisory business, if different from Item I.A.: LAKSHMI CAPITAL MANAGEMENT LLC
List on Section I.B. of Schedule D any additional names under which you conduct your advisory business.
If this filing is reporting a change in your legal name (Item l.A.) or primary business name (Item I.B.), enter the new name and specify whether the name change is of
r"]your legal name or lj your primary business name:
(1) If you are registered with the SEC as an investment adviser, your SEC file number:
If you report to the SEC as an exempt reporting adviser, your SEC file number:
If you have a number {"CRD Number") assigned by the FINRA's CRD system or by the IARD system, your CRD number:
If your firm does not have a CRD number, skip this Item I.E. Do not provide the CRD number of one of your officers, employees, or affiliates.
Principal Office and Place of Business (1) Address (do not use a P.O. Box):
Number and Street 1: Number and Street 2:
i City: State: Country: ZIP+4/Postal Code:
j
I If this address is a private residence, check this box: 17
i
i
I List on Section l.F. of Schedule D any office, other than your principal office and place of business, at which you conduct investment advisory business. If
\ you are applying for registration, or are registered, with one or more state securities authorities, you must list all of your offices in the state or states to
j which you are applying for registration or with whom you are registered. If you are applying for SEC registration, if you are registered only with the SEC, or
i if you are reporting to the SEC as an exempt reporting adviser, list the largest five offices in terms of numbers of employees.
|
! (2) Days of week that you normally conduct business at your principal office and place of business:
| 0 Monday - Friday ®Other: BY APP0INTMENT
Normal business hours at this location: j VARIES
Telephone number at this location: 310-243-6417
Facsimile number at this location: 888-809-6774
Mailing address, if different from your principal office and place of business address:
Number and Street 1: Number and Street 2:
City: State: Country: ZIP+4/Postal Code:
If this address is a private residence, check this box: lj
If you are a sole proprietor, state your full residence address, if different from your principal office and place of business address in Item l.F.:
Number and Street 1: Number and Street 2:
City: State: Country: ZIP+4/Postal Code:
Yes No
Do you have one or more websites? _ (t
I If "yes," list all website addresses on Section 1.1. of Schedule D. If a website address serves as a portal through which to access other information you have published on the web, you may list the portal without listing addresses for all of the other information. Some advisers may need to list more than one portal
• address. Do not provide individual electronic mail (e-mail) addresses in response to this Item.
j
i J. Provide the name and contact information of your Chief Compliance Officer: If you are an exempt reporting adviser, you must provide the contact
\ information for your Chief Compliance Officer, if you have one. If not, you must complete Item l.K. below.
j Name: Other titles, if any:
| Telephone number: Facsimile number:
i Number and Street 1: Number and Street 2:
I
j City: State: Country: ZIP+4/Postal Code:
i
j Electronic mail (e-mail) address, if Chief Compliance Officer has one:
j K. Additional Regulatory Contact Person: If a person other than the Chief Compliance Officer is authorized to receive information and respond to questions
j about this Form ADV, you may provide that information here.
j Name: Titles:
| Telephone number: Facsimile number:
! Number and Street 1: Number and Street 2:
: City: State: Country: ZIP+4/Postal Code:
i
j Electronic mail (e-mail) address, if contact person has one:
Yes No
I
j L. Do you maintain some or all of the books and records you are required to keep under Section 204 of the Advisers Act, or similar state law, (t, £,
| somewhere other than your principal office and place of business?
j If "yes," complete Section l.L. of Schedule D.
! Yes No
i
M. Are you registered with a foreign financial regulatory authority? p; ^
Answer "no" if you are not registered with a foreign financial regulatory authority, even if you have an affiliate that is registered with a foreign financial
regulatory authority. If "yes," complete Section l.M. of Schedule D. ;
Yes No j
N. Are you a public reporting company under Sections 12 or 15(d) of the Securities Exchange Act of 1934? f, (t If "yes," provide your CIK number (Central Index Key number that the SEC assigns to each public reporting company): j
Yes No I
; O. Did you have $1 billion or more in assets on the last day of your most recent fiscal year? (~, (t, j ; i
I P. Provide your Legal Entity Identifier if you have one: :
j j | A legal entity identifier is a unique number that companies use to identify each other in the financial marketplace. In the first half of 2011, the legal entity j
! identifier standard was still in development. You may not have a legal entity identifier. j
SECTION I.B. Other Business Names
No Information Filed
! SECTION l.F. Other Offices
No Information Filed
i SECTION 1.1. Website Addresses
|| List your website addresses. You must complete a separate Schedule D Section 1.1. for each website address.
Ii
jj Website Address:
! SECTION l.L. Location of Books and Records
j! Complete the following information for each location at which you keep your books and records, other than your principal office and place of business. You jj must complete a separate Schedule D Section l.L. for each location.
Ii Name of entity where books and records are kept: j; OFFICE
j!
il Number and Street 1: Number and Street 2:
City: State: Country: ZIP+4/Postal Code:
If this address is a private residence, check this box: 17
Telephone Number: Facsimile number:
818.667.1975
This is (check one):
(t, one of your branch offices or affiliates, p. a third-party unaffiliated recordkeeper. p other.
Briefly describe the books and records kept at this location: COPIES OF ALL BOOKS AND RECORDS.
SECTION l.M. Registration with Foreign Financial Regulatory Authorities
No Information Filed
Item 3 Form of Organization
How are you organized?
p Corporation
p Sole Proprietorship
p Limited Liability Partnership (LLP)
p Partnership
p. Limited Liability Company (LLC) (y, Limited Partnership (LP) p Other (specify):
If you are changing your response to this Item, see Part 1A Instruction 4.
In what month does your fiscal year end each year? DECEMBER
Under the laws of what state or country are you organized?
State Country 1 California United States
If you are a partnership, provide the name of the state or country under whose laws your partnership was formed. If you are a sole proprietor, provide the name of the state or country where you reside.
If you are changing your response to this Item, see Part 1A Instruction 4.
j Item 4 Successions _ _ j
! Yes No j
Are you, at the time of this filing, succeeding to the business of a registered investment adviser? p jj-,
If "yes", complete Item 4.B. and Section 4 of Schedule D.
Date of Succession: (MM/DD/YYYY)
If you have already reported this succession on a previous Form ADV filing, do not report the succession again. Instead, check "No." See Part 1A Instruction 4.
SECTION 4 Successions
No Information Filed
| Item 5 Information About Your Advisory Busmess - Employees, Clients, and Compensation _ _
! Responses to this Item help us understand your business, assist us in preparing for on-site examinations, and provide us with data we use when making ] regulatory policy. Part 1A Instruction 5.a. provides additional guidance to newly formed advisers for completing this Item 5.
Employees
If you are organized as a sole proprietorship, include yourself as an employee in your responses to Item 5. A. and Items S.B.(l), (2), (3), (4), and (5). If an employee performs more than one function, you should count that employee in each of your responses to Items 5.B.(1), (2), (3), (4), and (5).
Approximately how many employees do you have7 Include full- and part-time employees but do not include any clerical workers.
i|1010|(1) Approximately how many of the employees reported in 5.A. perform investment advisory functions (including research)?|1010|Approximately how many of the employees reported in 5.A. are registered representatives of a broker-dealer? 0
Approximately how many of the employees reported in 5.A. are registered with one or more stare securities authorities as investment adviser representatives'!|1010|Approximately how many of the employees reported in 5.A. are registered with one or more state securities authorities as investment adviser representatives for an investment adviser other than you7|10 10|Approximately how many of the employees reported in 5.A. are licensed agents of an insurance company or agency? 0
Approximately how many firms or other persons solicit advisory clients on your behalf? 0
In your response to Item 5.B.(6), do not count any of your employees and count a firm only once - do not count each of the firm's employees that solicit on your behalf.
I
i i
i Clients
In your responses to Items 5.C. and 5.D. do not include as "clients" the investors in a private fund you advise, unless you have a separate advisory relationship with those investors.
(1) To approximately how many clients did you provide investment advisory services during your most recently completed fiscal year?
Co ^ 1-10 C n-25
C 26-100 C More than 100
If more than 100, how many? (round to the nearest 100) (2) Approximately what percentage of your clients are non-United States persons7 0%
For purposes of this Item 5.D., the category "individuals" includes trusts, estates, and 401(k) plans and IRAs of individuals and their family members, but does not include businesses organized as sole proprietorships. The category "business development companies" consists of companies that have made an election pursuant to section 54 of the Investment Company Act of 1940. Unless you provide advisory services pursuant to an investment advisory contract to an investment company registered under the Investment Company Act of 1940, check "None" in response to Item S.D.(l)(d) and do not check any of the boxes in response to Item 5.D.(2)(d).
(1) What types of clients do you have? Indicate the approximate percentage that each type of client comprises of your total number of clients. If a client fits into more than one category, check all that apply.
None Up to 10% 11-25% 26-50% 51-75% 76-99% 100%
Individuals (other than high net worth individuals) C. C< C <• C C. C
High net worth individuals C C C. (> C- C C
Banking or thrift institutions Investment companies
Business development companies
Pooled investment vehicles (other than investment companies)
Pension and profit sharing plans (but not the plan participants)
Charitable organizations
(i) Corporations or other businesses not listed above
(j) State or municipal government entities
(k) Other investment advisers
(I) Insurance companies
(m) Other:
(f <•: <•¦
O
o r r <•.
o c c c c o
r, r c r. r r. c c c c
c r c c c r
c c o c
o o c c r r o c c o
c c c c c c c o c
c r c c o c
c c c
None C
r fr (•
<•
f?
c
Up to 25% C C O C
r o (f r r r r o r
Up to 50%
o r c o r c c c r
Up to 75%
C
r c o r n c r
r r r c
>75%
o r c c r c o c o c r c r
(2) Indicate the approximate amount of your regulatory assets under management (reported in Item 5.F. below) attributable to each of the following type of client. If a client fits into more than one category, check all that apply.
Individuals (other than high net worth individuals)
High net worth individuals
Banking or thrift institutions
Investment companies
Business development companies
Pooled investment vehicles (other than investment companies)
Pension and profit sharing plans (but not the plan participants)
Charitable organizations
(i) Corporations or other businesses not listed above
(j) State or municipal government entities
(k) Other investment advisers
(I) Insurance companies
(m) Other:
Compensation Arrangements
E. You are compensated for your investment advisory services by (check all that apply): l< (1) A percentage of assets under your management I""1 (2) Hourly charges
17 (3) Subscription fees (for a newsletter or periodical)
H- (4) Fixed fees (other than subscription fees)
^ (5) Commissions
17 (6) Performance-based fees
n (7) Other (specify):
; Item 5 Information About yj^4^Advisory_Business - Regulatory Assets Under^lanagement ! Regulatory Assets Under Management
Do you provide continuous and regular supervisory or management services to securities portfolios7
If yes, what is the amount of your regulatory assets under management and total number of accounts?
U.S. Dollar Amount Total Number of Accounts
Discretionary: (a) $ 282,700 (d) 7
Non-Discretionary: (b) $ 206,600 (e) 1
Total: (c) $ 489,300 (0 8
No ;
C i
Part 1A Instruction 5.b. explains how to calculate your regulatory assets under management. You must follow these instructions carefully when completing this Item.
[Item 5 Information About Your Advisory Business - Advisory Activities
! Advisory Activities
j
I G. What type(s) of advisory services do you provide7 Check all that apply,
i (1) Financial planning services
! 17 (2) Portfolio management for individuals and/or small businesses
' C (3) Portfolio management for investment companies (as well as "business development companies" that have made an election pursuant to
section 54 of the Investment Company Act of 1940) lj (4) Portfolio management for pooled investment vehicles (other than investment companies)
17 (5) Portfolio management for businesses (other than small businesses) or institutional clients (other than registered investment companies and
other pooled investment vehicles) rj (6) Pension consulting services
(7) Selection of other advisers (including private fund managers) 17 (8) Publication of periodicals or newsletters n (9) Security ratings or pricing services I"j (10) Market timing services
(11) Educational seminars/workshops (j (12) Other(specify):
j Do not check Item 5.G.(3) unless you provide advisory services pursuant to an investment advisory contract to an investment company registered under the ! Investment Company Act of 1940, including as a subadviser. If you check Item 5.G.(3), report the 811 or 814 number of the investment company or ; investment companies to which you provide advice in Section 5.G.(3) of Schedule D.
! H. If you provide financial planning services, to how many clients did you provide these services during your last fiscal year?
i (t 0
! (-1-10
i C 11 " 25
I c 26-50
i f~, 51 - 100
| ,<-, 101 - 250
! (~, 251 - 500
| p, More than 500
! If more than 500, how many?
'¦ (round to the nearest 500)
i In your responses to this Item 5.H., do not include as "clients" the investors in a private fund you advise, unless you have a separate advisory relationship
j with those investors.
j I. If you participate in a wrap fee program, do you (check all that apply):
j rJI (i) sponsor the wrap fee program?
j (2) act as a portfolio manager for the wrap fee program?
If you are a portfolio manager for a wrap fee program, list the names of the programs and their sponsors in Section 5.1.(2) of Schedule D.
j
| If your involvement in a wrap fee program is limited to recommending wrap fee programs to your clients, or you advise a mutual fund that is offered through a j wrap fee program, do not check either Item 5.1.(1) or 5.1.(2).
Yes No
i J. In response to Item 4.B. of Part 2A of Form ADV, do you indicate that you provide investment advice only with respect to limited types of P ;
i investments? I
{SECTION 5.G.(3) Advisers to Registered Investment Companies and Business Development Companies
|
! No Information Filed
SECTION 5.1.(2) Wrap Fee Programs
No Information Filed
i Item 6 Other Business Activities
! In this Item, we request information about your firm's other business activities.
A. You are actively engaged in business as a (check all that apply):
r~i (1) broker-dealer (registered or unregistered)
F- (2) registered representative of a broker-dealer
I* (3) commodity pool operator or commodity trading advisor (whether registered or exempt from registration)
^ (4) futures commission merchant
17 (5) real estate broker, dealer, or agent
insurance broker or agent
bank (including a separately identifiable department or division of a bank)
ri! (8) trust company
'I¦¦¦ (9) registered municipal advisor
f~! (10) registered security-based swap dealer
IT (11) major security-based swap participant I
I- (12) accountant or accounting firm
IT (13) lawyer or law firm
fT (14) other financial product salesperson (specify): !
If you engage in other business using a name that is different from the names reported in Items l.A. or I.B, complete Section 6.A. of Schedule D. i
Yes No j
B. (1) Are you actively engaged in any other business not listed in Item 6.A. (other than giving investment advice)? p (2) If yes, is this other business your primary business? p p. ;
If "yes," describe this other business on Section 6.B.(2) of Schedule D, and if you engage in this business under a different name, provide that name.
Yes No
(3) Do you sell products or provide services other than investment advice to your advisory clients? p
If "yes," describe this other business on Section 6.B.(3) of Schedule D, and if you engage in this business under a different name, provide that name.
SECTION 6.A. Names of Your Other Businesses
If you are actively engaged in other business using a different name, provide that name and the other line(s) of business. Other Business Name: LAKSHMI CAPITAL MANAGEMENT LLC
Other line(s) of business in which you engage using this name (check all that apply):
IT (1) broker-dealer (registered or unregistered)
C (2) registered representative of a broker-dealer j Hj (3) commodity pool operator or commodity trading advisor (whether registered or exempt from registration) i: F!) (4) futures commission merchant |! 17 (5) real estate broker, dealer, or agent :! IT (6) insurance broker or agent
lj T (7) bank (including a separately identifiable department or division of a bank)
jj n (8) trust company
j| (9) registered municipal advisor
jj T (io) registered security-based swap dealer
j! T (ii) major security-based swap participant
jj (12) accountant or accounting firm
!i ITS (13) lawyer or law firm
jj l"j (14) other financial product salesperson (specify):
[SECTION 6.B.(2) Description of Primary Business
Describe your primary business (not your investment advisory business): If you engage in that business under a different name, provide that name:
j SECTION 6.B.(3) Description of Other Products and Services
i Describe other products or services you sell to your client, You may omit products and services that you listed in Section 6.B.(2) above.
| REAL ESTATE
i If you engage in that business under a different name, provide that name.
i
}ltern_7 Financial Industry Affiliations^ ___ ______ _ _ i
r"* ~ ¦ "* ' "'_" "'—""' i
i In this Item, we request information about your financial industry affiliations and activities. This information identifies areas in which conflicts of interest may ; | occur between you and your clients.
I A. This part of Item 7 requires you to provide information about you and your related persons, including foreign affiliates. Your related persons are all of your j
advisory affiliates and any person that is under common control with you. j
You have a related person that is a (check all that apply): I
_. i
lj (1) broker-dealer, municipal securities dealer, or government securities broker or dealer (registered or unregistered) !
T (2) other investment adviser (including financial planners)
IT (3) registered municipal advisor
r. (4) registered security-based swap dealer
I". (5) major security-based swap participant •
(6) commodity pool operator or commodity trading advisor (whether registered or exempt from registration)
l~i (7) futures commission merchant
r~ (8) banking or thrift institution
I"!1 (9) trust company
j (io) accountant or accounting firm
; IT (ii) lawyer or law firm
¦ J~ (12) insurance company or agency
j l"_ (13) pension consultant
! r__ (14) real estate broker or dealer
IT (15) sponsor or syndicator of limited partnerships (or equivalent), excluding pooled investment vehicles
i r~: (16) sponsor, general partner, managing member (or equivalent) of pooled investment vehicles
I
For each related person, including foreign affiliates that may not be registered or required to be registered in the United States, complete Section 7.A. of
j Schedule D.
i
j You do not need to complete Section 7. A. of Schedule D for any related person if: (1) you have no business dealings with the related person in connection with
| advisory services you provide to your clients; (2) you do not conduct shared operations with the related person; (3) you do not refer clients or business to the
! related person, and the related person does not refer prospective clients or business to you; (4) you do not share supervised persons or premises with the
I related person; and (5) you have no reason to believe that your relationship with the related person otherwise creates a conflict of interest with your clients.
j You must complete Section 7.A. of Schedule D for each related person acting as qualified custodian in connection with advisory services you provide to your I clients (other than any mutual fund transfer agent pursuant to rule 206(4)-2(b)(l)), regardless of whether you have determined the related person to be \ operationally independent under rule 206(4)-2 of the Advisers Act.
SECTION 7.A. Financial Industry Affiliations
No Information Filed
[Item 7 Private Fund Reporting\_ !
Yes No i
B. Are you an adviser to any private fund? p, (t.
If "yes," then for each private fund that you advise, you must complete a Section 7.B.(1) of Schedule D, except in certain circumstances described in the next j
sentence and in Instruction 6 of the Instructions to Part 1A. If another adviser reports this information with respect to any such private fund in Section 7.B.(1) of j
Schedule D of its Form ADV (e.g., if you are a subadviser), do not complete Section 7.B.(l) of Schedule D with respect to that private fund. You must, instead, j
complete Section 7.B.(2) of Schedule D.
In either case, if you seek to preserve the anonymity of a private fund client by maintaining its identity in your books and records in numerical or alphabetical !
code, or similar designation, pursuant to rule 204-2(d), you may identify the private fund in Section 7,B.(1) or 7.B.(2) of Schedule D using the same code or !
designation in place of the fund's name. I
SECTION 7.B.(1) Private Fund Reporting
No Information Filed
I SECTION 7.B.(2) Private Fund Reporting
i i
I No Information Filed
Item 8 Participation or^Interest in Client Transactions
In this Item, we request information about your participation and interest in yourc//enrs' transactions. This information identifies additional areas in which conflicts of interest may occur between you and your clients.
Like Item 7, Item 8 requires you to provide information about you and your related persons, including foreign affiliates.
I-
Proprietary Interest in Client Transactions
: A. Do you or any related person: Yes No
I (1) buy securities for yourself from advisory clients, or sell securities you own to advisory clients (principal transactions)? p (f
i
i (2) buy or sell for yourself securities (other than shares of mutual funds) that you also recommend to advisory clients? (t. p,
I (3) recommend securities (or other investment products) to advisory clients in which you or any related person has some other proprietary p (ownership) interest (other than those mentioned in Items 8.A.(1) or (2))?
i Sales Interest in Client Transactions
! B. Do you or any related person: Yes No
(1) as a broker-dealer or registered representative of a broker-dealer, execute securities trades for brokerage customers in which advisory p. (t.
I c//enr securities are sold to or bought from the brokerage customer (agency cross transactions)?
; (2) recommend purchase of securities to advisory clients for which you or any related person serves as underwriter, general or managing p. (?
| partner, or purchaser representative?
i (3) recommend purchase or sale of securities to advisory clients for which you or any related person has any other sales interest (other than p (?, the receipt of sales commissions as a broker or registered representative of a broker-dealer)?
I
Investment or Brokerage Discretion
I C. Do you or any related person have discretionary authority to determine the: Yes No
(1) securities to be bought or sold for a client's account? (t, p
' (2) amount of securities to be bought or sold for a client's account? (t p
| (3) broker or dealer to be used for a purchase or sale of securities for a client's account? p (?.
(4) commission rates to be paid to a broker or dealer for a client's securities transactions? p
i i
! D. If you answer "yes" to C.(3) above, are any of the brokers or dealers related persons? p p.
! E. Do you or any related person recommend brokers or dealers to clients? (t. p^
If you answer "yes" to E above, are any of the brokers or dealers related persons? p (?,
(1) Do you or any related person receive research or other products or services other than execution from a broker-dealer or a third party (f, p.
I ("soft dollar benefits") in connection with c//enr securities transactions?
i (2) If "yes" to G.(l) above, are all the "soft dollar benefits" you or any related persons receive eligible "research or brokerage services" under (? p,
| section 28(e) of the Securities Exchange Act of 1934?
i H. Do you or any related person, directly or indirectly, compensate any person for client referrals? p. (?
i
j 1. Do you or any related person, directly or indirectly, receive compensation from any person for client referrals? p. (t-
j ]
¦ In responding to Items 8.H and 8.1., consider all cash and non-cash compensation that you or a related person gave to (in answering Item 8.H) or received j from (in answering Item 8.1) any person in exchange for client referrals, including any bonus that is based, at least in part, on the number or amount of client referrals.
j Item 9 Custody _ _ __ __ _ _ ___
j In this Item, we ask you whether you or a related person has custody of c//'enr (other than clients that are investment companies registered under the ! Investment Company Act of 1940) assets and about your custodial practices.
(1) Do you have custody of any advisory clients': Yes No
cash or bank accounts? p
securities? p,
If you are registering or registered with the SEC, answer "No" to Item 9.A.(l)(a) and (b) if you have custody solely because (i) you deduct your advisory fees directly from your clients' accounts, or (ii) a related person has custody of client assets in connection with advisory services you provide to clients, but you have I overcome the presumption that you are not operationally independent (pursuant to Advisers Act rule 206(4)-(2)(d)(5)) from the related person.
(2) If you checked "yes" to Item 9.A.(l)(a) or (b), what is the approximate amount of client funds and securities and total number of clients for which you have custody:
U.S. Dollar Amount Total Number of Clients
(a) $ (b)
If you are registering or registered with the SEC and you have custody solely because you deduct your advisory fees directly from your clients' accounts, do not include the amount of those assets and the number of those clients in your response to Item 9.A.(2). If your related person has custody of client assets in connection with advisory services you provide to clients, do not include the amount of those assets and number of those clients in your response to 9.A.(2). Instead, include that information in your response to Item 9.B.(2).
(1) In connection with advisory services you provide to clients, do any of your related persons have custody of any of your advisory clients': Yes No
cash or bank accounts? p. (r
securities' p (t
You are required to answer this item regardless of how you answered Item 9.A.(l)(a) or (b).
(2) If you checked "yes" to Item 9.B.(l)(a) or (b), what is the approximate amount of client funds and securities and total number of clients for which your related persons have custody:
U.S. Dollar Amount (a) $
Total Number of Clients (b)
C. If you or your related persons have custody of client funds or securities in connection with advisory services you provide to clients, check all the following
that apply:
A qualified custodian(s) sends account statements at least quarterly to the investors in the pooled investment vehicle(s) you manage. H !
An independent public accountant audits annually the pooled investment vehicle(s) that you manage and the audited financial statements IT)
| are distributed to the investors in the pools. j
j (3) An independent public accountant conducts an annual surprise examination of c//enf funds and securities. rjj j
I (4) An independent public accountant prepares an internal control report with respect to custodial services when you or your related persons T I
j are qualified custodians for client funds and securities. '
i I
| If you checked Item 9.C.(2), C.(3) or C.(4), list in Section 9.C. of Schedule D the accountants that are engaged to perform the audit or examination or prepare j
| an internal control report. (If you checked Item 9.C.(2), you do not have to list auditor information in Section 9.C. of Schedule D if you already provided this
| information with respect to the private funds you advise in Section 7.B.(1) of Schedule D). j
j ' !
D. Do you or your relatedperson(s) act as qualified custodians for your clients in connection with advisory services you provide to clients7 Yes No j
you act as a qualified custodian p, '
your related person(s) act as qualified custodian(s) p £ j
If you checked "yes" to Item 9.D.(2), all related persons that act as qualified custodians (other than any mutual fund transfer agent pursuant to rule I
206(4)-2(b)(l)) must be identified in Section 7. A. of Schedule D, regardless of whether you have determined the related person to be operationally independent under rule 206(4)-2 of the Advisers Act.
E. If you are filing your annual updating amendment and you were subject to a surprise examination by an independent public accountant during your last | fiscal year, provide the date (MM/YYYY) the examination commenced: i
j |
j F. If you or your related persons have custody of client funds or securities, how many persons, including, but not limited to, you and your related persons, act j
I as qualified custodians for your clients in connection with advisory services you provide to clients? !
I SECTION 9.C. Independent Public Accountant
No Information Filed
Item ^OControl Persons
In this Item, we ask you to identify every person that, directly or indirectly, controls you.
If you are submitting an initial application or report, you must complete Schedule A and Schedule B. Schedule A asks for information about your direct owners j and executive officers. Schedule B asks for information about your indirect owners. If this is an amendment and you are updating information you reported i on either Schedule A or Schedule B (or both) that you filed with your initial application or report, you must complete Schedule C.
i Yes No
i
| A. Does any person not named in Item l.A. or Schedules A, B, or C, directly or indirectly, control your management or policies? p. ! If yes, complete Section 10. A. of Schedule D.
i B. If any person named in Schedules A, B, or C or in Section 10.A. of Schedule D is a public reporting company under Sections 12 or 15(d) of the Securities ; Exchange Act of 1934, please complete Section 10.B. of Schedule D.
SECTION 10.A. Control Persons
i
j No Information Filed
j
[SECTION 10.B. Control Person Public Reporting Companies
i
i No Information Filed
litem 11 Disclosure Information
! In this Item, we ask for information about your disciplinary history and the disciplinary history of all your advisory affiliates. We use this information to
: determine whether to grant your application for registration, to decide whether to revoke your registration or to place limitations on your activities as an
: investment adviser, and to identify potential problem areas to focus on during our on-site examinations. One event may result in "yes" answers to more than
; one of the questions below.
j Your advisory affiliates are: (1) all of your current employees (other than employees performing only clerical, administrative, support or similar functions); (2) all ¦ of your officers, partners, or directors (or any person performing similar functions); and (3) all persons directly or indirectly controlling you or controlled by you. j If you are a "separately identifiable department or division" (SID) of a bank, see the Glossary of Terms to determine who your advisory affiliates are.
i If you are registered or registering with the SEC or if you are an exempt reporting adviser, you may limit your disclosure of any event listed in Item 11 to ten years i following the date of the event. If you are registered or registering with a state, you must respond to the questions as posed; you may, therefore, limit your j | disclosure to ten years following the date of an event only in responding to Items ll.A.(l), ll.A.(2), ll.B.(l), 11.3.(2), ll.D.(4), and ll.H.(l)(a). For purposes of I calculating this ten-year period, the date of an event is the date the final order, judgment, or decree was entered, or the date any rights of appeal from preliminary
! orders, judgments, or decrees lapsed.
i
' You must complete the appropriate Disclosure Reporting Page ("DRP") for "yes" answers to the questions in this Item 11.
Yes No
Do any of the events below involve you or any of your supervised persons? p
For "ves" answers to the following questions, complete a Criminal Action DRP:
j A. In the past ten years, have you or any advisory affiliate: Yes No
! (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony? p (t,
j (2) been charged with any felony? p. (t,
If you are registered or registering with the SEC, or if you are reporting as an exempt reporting adviser, you may limit your response to Item ll.A.(2) to charges that are currently pending.
In the past ten years, have you or any advisory affiliate:
been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to a misdemeanor involving: p (?:
investments or an investment-related business, or any fraud, false statements, or omissions, wrongful taking of property, bribery, perjury,
forgery, counterfeiting, extortion, or a conspiracy to commit any of these offenses?
been charged with a misdemeanor listed in Item 11.B.(l)? p.
If you are registered or registering with the SEC, or if you are reporting as an exempt reporting adviser, you may limit your response to Item ll.B.(2) to charges that are currently pending.
For "ves" answers to the following questions, complete a Regulatory Action DRP:
Has the SEC or the Commodity Futures Trading Commission (CFTC) ever: Yes No
found you or any advisory affiliate to have made a false statement or omission? p (t
found you or any advisory affiliate to have been involved in a violation of SEC or CFTC regulations or statutes? p (t,
found you or any advisory affiliate to have been a cause of an investment-related business having its authorization to do business denied, p
suspended, revoked, or restricted?
entered an order against you or any advisory affiliate in connection with investment-related activity? p (t,
imposed a civil money penalty on you or any advisory affiliate, or ordered you or any advisory affiliate to cease and desist from any activity? p. (t
Has any other federal regulatory agency, any state regulatory agency, or any foreign financial regulatory authority:
ever found you or any advisory affiliate to have made a false statement or omission, or been dishonest, unfair, or unethical? p ever found you or any advisory affiliate to have been involved in a violation of investment-related regulations or statutes? p (?:
ever found you or any advisory affiliate to have been a cause of an investment-related business having its authorization to do business p (?, denied, suspended, revoked, or restricted?
in the past ten years, entered an order against you or any advisory affiliate in connection with an investment-related activity? p (t.
ever denied, suspended, or revoked your or any advisory affiliate's registration or license, or otherwise prevented you or any advisory p, £
affiliate, by order, from associating with an investment-related business or restricted your or any advisory affiliate's activity?
Has any self-regulatory organization or commodities exchange ever:
found you or any advisory affiliate to have made a false statement or omission? p. (t
found you or any advisory affiliate to have been involved in a violation of its rules (other than a violation designated as a "minor rule p (?,
violation" under a plan approved by the SEC)?
found you or any advisory affiliate to have been the cause of an investment-related business having its authorization to do business denied, p; (?, suspended, revoked, or restricted?
disciplined you or any advisory affiliate by expelling or suspending you or the advisory affiliate from membership, barring or suspending you p (?. or the advisory affiliate from association with other members, or otherwise restricting your or the advisory affiliate's activities?
Has an authorization to act as an attorney, accountant, or federal contractor granted to you or any advisory affiliate ever been revoked or p (?:
suspended?
G. Are you or any advisory affiliate now the subject of any regulatory proceeding that could result in a "yes" answer to any part of Item 11.C, p 11.D., or 11.E.?
For "ves" answers to the following questions, complete a Civil Judicial Action DRP:
H. (1) Has any domestic or foreign court: Yes No
in the past ten years, enjoined you or any advisory affiliate in connection with any investment-related activity? p ^,
ever found that you or any advisory affiliate were involved in a violation of investment-related statutes or regulations? p (t
ever dismissed, pursuant to a settlement agreement, an investment-related civil action brought against you or any advisory affiliate by a p. (?,
state or foreign financial regulatory authority7
(2) Are you or any advisory affiliate now the subject of any civil proceeding that could result in a "yes" answer to any part of Item ll.H.(l)? p (f;
Item 12 Small Businesses
The SEC is required by the Regulatory Flexibility Act to consider the effect of its regulations on small entities. In order to do this, we need to determine whether you meet the definition of "small business" or "small organization" under rule 0-7.
Answer this Item 12 only if you are registered or registering with the SEC and you indicated in response to Item 5.F.(2)(c) that you have regulatory assets under management of less than $25 million. You are not required to answer this Item 12 if you are filing for initial registration as a state adviser, amending a current state registration, or switching from SEC to state registration.
For purposes of this Item 12 only:
Total Assets refers to the total assets of a firm, rather than the assets managed on behalf of clients. In determining your or another person's total !
assets, you may use the total assets shown on a current balance sheet (but use total assets reported on a consolidated balance sheet with j
subsidiaries included, if that amount is larger). Control means the power to direct or cause the direction of the management or policies of a person, whether through ownership of securities, by i
contract, or otherwise. Any person that directly or indirectly has the right to vote 25 percent or more of the voting securities, or is entitled to 25 percent I
or more of the profits, of another person is presumed to control the other person. !
Yes No
Did you have total assets of $5 million or more on the last day of your most recent fiscal year? p. p,
If "yes," you do not need to answer Items 12. B. and 12. C.
Do you:
control another investment adviser that had regulatory assets under management (calculated in response to Item 5.F.(2)(c) of Form ADV) p. p. of $25 million or more on the last day of its most recent fiscal year?
control another person (other than a natural person) that had total assets of $5 million or more on the last day of its most recent fiscal p p
year?
Are you:
controlled by or under common control with another investment adviser that had regulatory assets under management (calculated in CO response to Item 5.F.(2)(c) of Form ADV) of $25 million or more on the last day of its most recent fiscal year?
controlled by or under common control with another person (other than a natural person) that had total assets of $5 million or more on the £¦ p last day of its most recent fiscal year?
Schedule A
j
Direct Owners and Executive Officers
Complete Schedule A only if you are submitting an initial application or report. Schedule A asks for information about your direct owners and executive j
officers. Use Schedule C to amend this information. |
Direct Owners and Executive Officers. List below the names of: j
each Chief Executive Officer, Chief Financial Officer, Chief Operations Officer, Chief Legal Officer, Chief Compliance Officer(Chief Compliance Officer is j
required if you are registered or applying for registration and cannot be more than one individual), director, and any other individuals with similar j
status or functions; j
if you are organized as a corporation, each shareholder that is a direct owner of 5% or more of a class of your voting securities, unless you are a j
public reporting company (a company subject to Section 12 or 15(d) of the Exchange Act); I
Direct owners include any person that owns, beneficially owns, has the right to vote, or has the power to sell or direct the sale of, 5% or more of a j
class of your voting securities. For purposes of this Schedule, a person beneficially owns any securities: (i) owned by his/her child, stepchild, grandchild, parent, stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law, sharing j
the same residence; or (ii) that he/she has the right to acquire, within 60 days, through the exercise of any option, warrant, or right to purchase the I
security. if you are organized as a partnership, all general partners and those limited and special partners that have the right to receive upon dissolution, or
have contributed, 5% or more of your capital; j
in the case of a trust that directly owns 5% or more of a class of your voting securities, or that has the right to receive upon dissolution, or has contributed, 5% or more of your capital, the trust and each trustee; and
if you are organized as a limited liability company ("LLC"), (i) those members that have the right to receive upon dissolution, or have contributed, 5% or more of your capital, and (n) if managed by elected managers, all elected managers.
Do you have any indirect owners to be reported on Schedule B? p Yes p No
In the DE/FE/I column below, enter "DE" if the owner is a domestic entity, "FE" if the owner is an entity incorporated or domiciled in a foreign country, or j
! "I" if the owner or executive officer is an individual.
I 5. Complete the Title or Status column by entering board/management titles; status as partner, trustee, sole proprietor, elected manager, shareholder, or
i member; and for shareholders or members, the class of securities owned (if more than one is issued).
16. Ownership codes are: NA - less than 5% B - 10% but less than 25% D - 50% but less than 75%
j A - 5% but less than 10% C - 25% but less than 50% E - 75% or more
| 7. (a) In the Control Person column, enter "Yes" if the person has control as defined in the Glossary of Terms to Form ADV, and enter "No" if the person does
I not have control. Note that under this definition, most executive officers and all 25% owners, general partners, elected managers, and trustees are
control persons.
In the PR column, enter "PR" if the owner is a public reporting company under Sections 12 or 15(d) of the Exchange Act.
Complete each column.
FULL LEGAL NAME (Individuals: Last Name, First Name, Middle Name) DE/FE/I Status Date Status Acquired MM/YYYY Ownership Code Control Person PR CRD No. If None: S.S. No. and Date of Birth, IRS Tax No. or Employer ID No.
THANGAVEL, ANANTHAN, KUMAR I MANAGING MEMBER 04/2009 E Y N
! Schedule B !
I ¦ j
j Indirect Owners !
j 1. Complete Schedule B only if you are submitting an initial application. Schedule B asks for information about your indirect owners; you must first complete
' Schedule A, which asks for information about your direct owners. Use Schedule C to amend this information.
i
] 2. Indirect Owners. With respect to each owner listed on Schedule A (except individual owners), list below:
j (a) in the case of an owner that is a corporation, each of its shareholders that beneficially owns, has the right to vote, or has the power to sell or direct ;
the sale of, 25% or more of a class of a voting security of that corporation; I
! j
For purposes of this Schedule, a person beneficially owns any securities: (i) owned by his/her child, stepchild, grandchild, parent, stepparent, !
grandparent, spouse, sibling, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law, sharing the same residence; j
or (ii) that he/she has the right to acquire, within 60 days, through the exercise of any option, warrant, or right to purchase the security.
j (b) in the case of an owner that is a partnership, a|l general partners and those limited and special partners that have the right to receive upon !
I dissolution, or have contributed, 25% or more of the partnership's capital; !
i (c) in the case of an owner that is a trust, the trust and each trustee; and !
! (d) in the case of an owner that is a limited liability company ("LLC"), (i) those members that have the right to receive upon dissolution, or have i
I contributed, 25% or more of the LLC's capital, and (ii) if managed by elected managers, all elected managers.
' 3. Continue up the chain of ownership listing all 25% owners at each level. Once a public reporting company (a company subject to Sections 12 or 15(d) of ¦
the Exchange Act) is reached, no further ownership information need be given. I
i
In the DE/FE/I column below, enter "DE" if the owner is a domestic entity, "FE" if the owner is an entity incorporated or domiciled in a foreign country, or
"I" if the owner is an individual. !
Complete the Status column by entering the owner's status as partner, trustee, elected manager, shareholder, or member; and for shareholders or j
j members, the class of securities owned (if more than one is issued).
j 6. Ownership codes are: C - 25% but less than 50% E - 75% or more j
; D - 50% but less than 75% F - Other (general partner, trustee, or elected manager) j
7. (a) In the Control Person column, enter "Yes" if the person has control as defined in the Glossary of Terms to Form ADV, and enter "No" if the person does <
not have control. Note that under this definition, most executive officers and all 25% owners, general partners, elected managers, and trustees are ;
control persons. j
(b) In the PR column, enter "PR" if the owner is a public reporting company under Sections 12 or 15(d) of the Exchange Act. j
! (c) Complete each column. i
| j
j No Information Filed j
L __ _ _ __ __ i
[Schedule p - Miscellaneous
i You may use the space below to explain a response to an Item or to provide any other information.
I DRP Pages
CRIMINAL DISCLOSURE REPORTING PAGE (ADV)
GENERAL INSTRUCTIONS
This Disclosure Reporting Page (DRP ADV) is an q INITIAL Q_ ft AMENDED response used to report details for affirmative responses to Items 11.A and
]!;11.B of Form ADV.
i;:
j'- Criminal j;;Check item(s) being responded to:
iii nn.A(i) rn.A(2) nil.bo) ph.bu)
Use'a separate DRP for each event or proceeding . The same event or proceeding may be reported for more than one person or entity using one DRP. File with a completed Execution Page.
!
! Multiple counts of the same charge arising out of the same event(s) should be reported on the same DRP. Unrelated criminal actions, including separate cases arising out of the same event, must be reported on separate DRPs. Use this DRP to report all charges arising out of the same event. One event may result in more than one affirmative answer to the items listed above.
PART I
The person(s) or entity(ies) for whom this DRP is being filed is (are): (I, You (the advisory firm)
c You and one or more of your advjSQry _ffi/(afes C 0ne °r more °f Y°ur advisory affiliates
If this DRP is being filed for an advisory affiliate, give the full name of the advisory affiliate below (for individuals, Last name, First name, Middle name). If the advisory affiliate has a CRD number, provide that number. If not, indicate "non-registered" by checking the appropriate box.
ADV DRP - ADVISORY AFFILIATE
No Information Filed
Hi
D This DRP should be removed from the ADV record because the advisory affiliate(s) is no longer associated with the adviser.
,|| n This DRP should be removed from the ADV record because: (1) the event or proceeding occurred more than ten years ago or (2) the adviser is
''' registered or applying for registration with the SEC and the event was resolved in the adviser's or advisory affiliate's favor.
L~i This DRP should be removed from the ADV record because it was filed in error, such as due to a clerical or data-entry mistake. Explain the circumstances:
If the advisory affiliate is registered through the IARD system or CRD system, has the advisory affiliate submitted a DRP (with Form ADV, BD or U-4) to the IARD or CRD for the event7 If the answer is "Yes," no other information on this DRP must be provided.
C Yes C No
NOTE: The completion of this form does not relieve the advisory affiliate of its obligation to update its IARD or CRD records. PART II
1. If charge(s) were brought against an organization over which you or an advisory affiliate exercise(d) control: Enter organization name, whether or not the organization was an investment-related business and your or the advisory affiliate position, title, or relationship.
Formal Charge(s) were brought in: (include name of Federal, Military, State or Foreign Court, Location of Court - City or County and State or Country, Docket/Case number).
STATE - CIRCUIT COURT OF COOK COUNTY, IL DOCKET # 042554 IN THE CIRCUIT COURT OF COOK COUNTY, IL
Event Disclosure Detail (Use this for both organizational and individual charges.)
Date First Charged (MM/DD/YYYY):
01/27/2004 & Exact O Explanation If not exact, provide explanation:
Event Disclosure Detail (include Charge(s)/Charge Descnption(s), and for each charge provide: (1) number of counts, (2) felony or misdemeanor, (3) plea for each charge, and (4) product type if charge is investment-related).
1 COUNT OF MISDEMEANOR THEFT OF SERVICE PLEAD NOT GUILTY CHARGE WAS DISMISSED AND EXPUNGED ON 02/07/2005.
Did any of the Charge(s) within the Event involve a feiony7 C. Yes No
Current status of the Event? C Pending C- On Appeal Final
Event Status Date (complete unless status is Pending) (MM/DD/YYYY):
02/07/2005 ® Exact Explanation If not exact, provide explanation:
Disposition Disclosure Detail:
Include for each charge (a) Disposition Type (e.g., convicted, acquitted, dismissed, pretrial, etc.), (b) Date, (c) Sentence/Penalty, (d) Duration (if sentence - suspension, probation, etc.), (e) Start Date of Penalty, (f) Penalty/Fine Amount, and (g) Date Paid. DISMISSED AND EXPUNGED ON 2/7/2005.
Provide a brief summary of circumstances leading to the charge(s) as well as the disposition. Include the relevant dates when the conduct which was the subject of the charge(s) occurred. (Your response must fit within the space provided.)
I WAS ACCUSED OF DINING AND DITCHING FROM A LOCAL RESTAURANT. UPON REQUESTING ANY AND ALL VIDEO EVIDENCE FROM THE RESTAURANT, THE RESTAURANT AND THE PROSECUTOR DID NOT PRODUCE THE EVIDENCE. THE JUDGE ORDERED THE CASE DISMISSED AND THE ARREST WAS EXPUNGED FROM MY RECORD.
I REGULATORY ACTION DISCLOSURE REPORTING PAGE (ADV)
I No Information Filed
CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (ADV)
No Information Filed
Arbitration DRPs
No Information Filed
Bond DRPs
No Information Filed
Judgment/Lien DRPs
No Information Filed
Part IB Item 1 - State Registration
You must complete this Part IB only if you are applying for registration, or are registered, as an investment adviser with any of the state securities authorities.
i Complete this Item 1 if you are submitting an initial application for state registration or requesting additional state registration(s). Check the boxes next to the states to which you are submitting this application. If you are already registered with at least one state and are applying for registration with an additional state or states, check the boxes next to the states in which you are applying for registration. Do not check the boxes next to the states in which you are currently registered or where you have an application for registration pending.
Jurisdictions
AL IT AK H AZ
ar
17 CA F~ CO
CT
n de ri dc n fl
D GA
GU |J HI
[?id--
i n il
\ ? IN
!? IA
? KS
D KY
LA
n me
MD
n ma
I ? MI | ? MN
i n ms
MO l~i MT IT NE
] r_ nv
I ? NH IT NJ
NM
NY
NC
ND
? OH ! H OK
n or
PA
n pr
RI
sc
SD
TN
TX
UT
VT
, n vi
|! ? VA
ii I-.
ij ? WA Il ? WV
i! r wi
I Part IB Item 2 - Additional Information
i Complete this Item 2A. only if the person responsible for supervision and compliance does not appear in Item 1J. or IK. of Form ADV Part 1A:
i
I A. Person responsible for supervision and compliance:
| Name: Title:
I Telephone: Fax:
i
! Number and Street 1: Number and Street 2:
| City: State: Country: ZIP+4/Postal Code:
' Email address, if available:
| If this address is a private residence, check this box: IT
Bond/Capital Information, if required by your home state
Name of Issuing Insurance Company:
Amount of Bond: $ .00
Bond Policy Number:
j Yes No
' (4) If required by your home state, are you in compliance with your home state's minimum capital requirements? (p: p,
j Part IB - Disclosure Questions
j BOND DISCLOSURE
! For "yes" answers to the following question, complete a Bond DRP. Yes No
! C. Has a bonding company ever denied, paid out on, or revoked a bond for you, any advisory affiliate, or any management person? p, (t
j JUDGMENT/LIEN DISCLOSURE
j For "yes" answers to the following question, complete a Judgment/Lien DRP. Yes No
j D. Are there any unsatisfied judgments or liens against you, any advisory affiliate, or any management person? p,
ARBITRATION DISCLOSURE
For "yes" answers to the following questions, complete an Arbitration DRP.
i E. Are you, any advisory affiliate, or any management person currently the subject of, or have you, any advisory affiliate, or any management
i person been the subject of, an arbitration claim alleging damages in excess of $2,500, involving any of the following: Yes No
' (1) any investment or an investment-related business or activity? p: (t.
j (2) fraud, false statement, or omission? p (?
| (3) theft, embezzlement, or other wrongful taking of property? p. p,
I (4) bribery, forgery, counterfeiting, or extortion? p ^,
(5) dishonest, unfair, or unethical practices? p (?,
I CIVIL JUDICIAL DISCLOSURE
| For "yes" answers to the following questions, complete a Civil Judicial Action DRP.
i F. Are you, any advisory affiliate, or any management person currently subject to, or have you, any advisory affiliate, or any management person
j been found liable in, a civil, self-regulatory organization, or administrative proceeding involving any of the following: Yes No
| (1) an investment or investment-related business or activity? p q
| (2) fraud, false statement, or omission? p p.
I (3) theft, embezzlement, or other wrongful taking of property? p ^
] (4) bribery, forgery, counterfeiting, or extortion? p (t
(5) dishonest, unfair, or unethical practices? p (?.
Part IB - Business Information
Other Business Activities j
Are you, any advisory affiliate, or any management person actively engaged in business as a(n) (check all that apply): ! lj Tax Preparer
Issuer of securities
Sponsor or syndicator of limited partnerships (or equivalent), excluding pooled investment vehicles ; [_ Sponsor, general partner, managing member (or equivalent) of pooled investment vehicles j 15. Real estate adviser j
If you, any advisory affiliate, or any management person are actively engaged in any business other than those listed in Item 6.A of Part 1A or Item ; 2.G(1) of Part IB, describe the business and the approximate amount of time spent on that business: j
If you provide financial planning services, the investments made based on those services at the end of your last fiscal year totaled: '
Securities Investments Non-Securities Investments
Under $100,000 p p,
$100,001 to $500,000 p p, i
$500,001 to $1,000,000 p p
$1,000,001 to $2,500,000 p p j
$2,500,001 to $5,000,000 p p More than $5,000,000 p. p, j
If securities investments are over $5,000,000, how much? (round to the nearest $1,000,000)
If non-securities investments are over $5,000,000, how much? (round to the nearest $1,000,000)
I. Custody Yes No
(1) Advisory Fees
Do you withdraw advisory fees directly from your clients' accounts? If you answered "yes", respond to the following: (? p
Do you send a copy of your invoice to the custodian or trustee at the same time that you send a copy to the client? (? p
Does the custodian send quarterly statements to your clients showing all disbursements for the custodian account, including the (j- p.
j • amount of the advisory fees?
¦ (c) Do your clients provide written authorization permitting you to be paid directly for their accounts held by the custodian or trustee? q. p
i (2) Pooled Investment Vehicles and Trusts
(a) (i) Do you or a related person act as a general partner, managing member, or person serving in a similar capacity, for any pooled p p,
j investment vehicle for which you are the adviser to the pooled investment vehicle, or for which you are the adviser to one or more
j of the investors in the pooled investment vehicle? If you answered "yes", respond to the following:
] (a) (ii) As the general partner, managing member, or person serving in a similar capacity, have you or a related person engaged any of
i the following to provide authority permitting each direct payment or any transfer of funds or securities from the account of the
pooled investment vehicle?
j Attorney p ^
| Independent certified public accountant p p
] Other independent party p p.
| Describe the independent party:
| For purposes of this Item 21.2(a), "Independent party" means a person that: (A) is engaged by the investment adviser to act as a gatekeeper for
j the payment of fees, expenses and capital withdrawals from the pooled investment; (B) does not control and is not controlled by and is not under
• common control with the investment adviser; (C) does not have, and has not had within the past two years, a material business relationship with
j the investment adviser; and (D) shall not negotiate or agree to have material business relations or commonly controlled relations with an
\ investment adviser for a period of two years after serving as the person engaged in an independent party agreement.
I
| (b) Do you or a related person act as investment adviser and a trustee for any trust, or act as a trustee for any trust in which your p
| advisory clients are beneficiaries of the trust?
! (3) Do you require the prepayment of fees of more than $500 per client and for six months or more in advance? p
; J. If you are organized as a sole proprietorship, please answer the following: Yes No
(1) (a) Have you passed, on or after January 1, 2000, the Series 65 examination? p p,
(b) Have you passed, on or after January 1, 2000, the Series 66 examination and also passed, at any time, the Series 7 examination? p p
j (2) (a) Do you have any investment advisory professional designations? p p
If "no",you do not need to answer Item 2.J(2)(b).
j (b) I have earned and I am in good standing with the organization that issued the following credential:
| fj Certified Financial Planner ("CFP")
j FT Chartered Financial Analyst ("CFA")
i fi Chartered Financial Consultant ("ChFC")
! V'. Chartered Investment Counselor ("CIC")
' IT. Personal Financial Specialist ("PFS")
• IT. None of the above
i (3) Your Social Security Number:
I i
! K. If you are organized other than as a sole proprietorship, please provide the following:
(1) Indicate the date you obtained your legal status. Date of formation: 05/09/2009
(2) Indicate your IRS Empl. Ident. No.:
I Part 2 _
| Amend, retire or file new brochures:
BrrcKiireiip.iJo?^^^ Broch^jreiName* Brbthufe.^y pe( s) v;ffiv^ri J
108205 FORM ADV PART 2 BROCHURE Individuals, High net worth individuals. Pension plans/profit sharing plans
| Execution Pages _ _
jj DOMESTIC INVESTMENT ADVISER EXECUTION PAGE
jj You must complete the following Execution Page to Form ADV. This execution page must be signed and attached to your initial submission of Form ADV to !j the SEC and all amendments.
i
! Appointment of Agent for Service of Process
j i
\\ By signing this Form ADV Execution Page, you, the undersigned adviser, irrevocably appoint the Secretary of State or other legally designated officer, of the state in which you maintain your principal office and place of business and any other state in which you are submitting a notice filing, as your agents to receive service, and agree that such persons may accept service on your behalf, of any notice, subpoena, summons, order instituting proceedings, demand for arbitration, or other process or papers, and you further agree that such service may be made by registered or certified mail, in any federal or state action, administrative proceeding or arbitration brought against you in any place subject to the jurisdiction of the United States, if the action, proceeding, or arbitration (a) arises out of any activity in connection with your investment advisory business that is subject to the jurisdiction of the United States, and (b) is founded, directly or indirectly, upon the provisions of: (i) the Securities Act of 1933, the Securities Exchange Act of 1934, the Trust Indenture Act of 1939,
j trie-Investment Company Act of 1940, or the Investment Advisers Act of 1940, or any rule or regulation under any of these acts, or (ii) the laws of the state in which you maintain your principal office and place of business or of any state in which you are submitting a notice filing.
Signature
I, the undersigned, sign this Form ADV on behalf of, and with the authority of, the investment adviser. The investment adviser and I both certify, under penalty of perjury under the laws of the United States of America, that the information and statements made in this ADV, including exhibits and any other information submitted, are true and correct, and that I am signing this Form ADV Execution Page as a free and voluntary act.
I certify that the adviser's books and records will be preserved and available for inspection as required by law. Finally, I authorize any person having custody or possession of these books and records to make them available to federal and state regulatory representatives.
Signature: Date: MM/DD/YYYY
ANANTHAN THANGAVEL 04/06/2017
Printed Name: Title:
ANANTHAN THANGAVEL MANAGING MEMBER
Adviser CRD Number:
I ^NON-RESIDENT INVESTMENT ADVISER EXECUTION PAGE
i! You must complete the following Execution Page to Form ADV. This execution page must be signed and attached to your initial submission of Form ADV to ii the SEC and all amendments.
1. Appointment of Agent for Service of Process
By signing this Form ADV Execution Page, you, the undersigned adviser, irrevocably appoint each of the Secretary of the SEC, and the Secretary of State or other legally designated officer, of any other state in which you are submitting a notice filing, as your agents to receive service, and agree that such j persons may accept service on your behalf, of any notice, subpoena, summons, order instituting proceedings, demand for arbitration, or other process or | papers, and you further agree that such service may be made by registered or certified mail, in any federal or state action, administrative proceeding or j arbitration brought against you in any place subject to the jurisdiction of the United States, if the action, proceeding or arbitration (a) arises out of any j activity in connection with your investment advisory business that is subject to the jurisdiction of the United States, and (b) is founded, directly or indirectly, | upon the provisions of: (i) the Securities Act of 1933, the Securities Exchange Act of 1934, the Trust Indenture Act of 1939, the Investment Company Act of | 1940, or the Investment Advisers Act of 1940, or any rule or regulation under any of these acts, or (n) the laws of any state in which you are submitting a notice filing.
Appointment and Consent: Effect on Partnerships
If you are organized as a partnership, this irrevocable power of attorney and consent to service of process will continue in effect if any partner withdraws from or is admitted to the partnership, provided that the admission or withdrawal does not create a new partnership. If the partnership dissolves, this irrevocable power of attorney and consent shall be in effect for any action brought against you or any of your former partners.
Non-Resident Investment Adviser Undertaking Regarding Books and Records
By signing this Form ADV, you also agree to provide, at your own expense, to the U.S. Securities and Exchange Commission at its principal office in
Washington D.C., at any Regional or District Office of the Commission, or at any one of its offices in the United States, as specified by the Commission, ij
correct, current, and complete copies of any or all records that you are required to maintain under Rule 204-2 under the Investment Advisers Act of 1940. ij
This undertaking shall be binding upon you, your heirs, successors and assigns, and any person subject to your written irrevocable consents or powers of j:
attorney or any of your general partners and managing agents. ii
jj
i Signature jj
I, the undersigned, sign this Form ADV on behalf of, and with the authority of, the non-resident investment adviser. The investment adviser and I both j certify, under penalty of perjury under the laws of the United States of America, that the information and statements made in this ADV, including exhibits i and any other information submitted, are true and correct, and that I am signing this Form ADV Execution Page as a free and voluntary act.
; j
I certify that the adviser's books and records will be preserved and available for inspection as required by law. Finally, I authorize any person having custody or possession of these books and records to make them available to federal and state regulatory representatives.
Signature: Date: MM/DD/YYYY
Printed Name: Title:
j:
ii Adviser CRD Number:
j STATE-REGISTERED INVESTMENT ADVISER EXECUTION PAGE _ _
ij You must complete the following Execution Page to Form ADV. This execution page must be signed and attached to your initial application for state j! registration and all amendments to registration.
1. ¦Appointment of Agent for Service of Process
', By signing this Form ADV Execution Page, you, the undersigned adviser, irrevocably appoint the legally designated officers and their successors, of the
j state in which you maintain your principal office and place of business and any other state in which you are applying for registration or amending your
; registration, as your agents to receive service, and agree that such persons may accept service on your behalf, of any notice, subpoena, summons, order
\ instituting proceedings, demand for arbitration, or other process or papers, and you further agree that such service may be made by registered or certified
; mail, in any federal or state action, administrative proceeding or arbitration brought against you in any place subject to the jurisdiction of the United States,
! if the action, proceeding, or arbitration (a) arises out of any activity in connection with your investment advisory business that is subject to the jurisdiction of
j the United States, and (b) is founded, directly or indirectly, upon the provisions of: (i) the Securities Act of 1933, the Securities Exchange Act of 1934, the
! Trust Indenture Act of 1939, the Investment Company Act of 1940, or the Investment Advisers Act of 1940, or any rule or regulation under any of these
j acts, or (ii) the laws of the state in which you maintain your principal office and place of business or of any state in which you are applying for registration or
j amending your registration.
2. State-Registered Investment Adviser Affidavit
If you are subject to state regulation, by signing this Form ADV, you represent that, you are in compliance with the registration requirements of the state in which you maintain your principal place of business and are in compliance with the bonding, capital, and recordkeeping requirements of that state.
Signature
; I, the undersigned, sign this Form ADV on behalf of, and with the authority of, the investment adviser. The investment adviser and I both certify, under j penalty of perjury under the laws of the United States of America, that the information and statements made in this ADV, including exhibits and any other I information submitted, are true and correct, and that I am signing this Form ADV Execution Page as a free and voluntary act.
1 I certify that the adviser's books and records will be preserved and available for inspection as required by law. Finally, I authorize any person having \ custody or possession of these books and records to make them available to federal and state regulatory representatives.
|i
|| Date: MM/DD/YYYY Printed Name:
j; 04/06/2017 ANANTHAN THANGAVEL
j| CRD Number:
;. Autnuri-cu-lynaLui/: Title:
jj ANANTHAN THANGAVEL MANAGING MEMBER
335 Schiller LLC 1596.0000 2
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Lakshmi Capital Management LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
[ ] a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR
[x] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
335 Schiller LLC
Business address of the Disclosing Party: 1907 North Beverly Drive
Beverly Hills, IL 90210
Telephone: (312) sio-isoo Fax: (312) 626-2414 Email: gdi-iattasiaw.com
Name of Contact person: George Lattas
Federal Employer Identification No. (if you have one): To follow.
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Application for zoning map amendment (planned development) for:
335-345 West Schiller Street; 1355-1369 North Sedgwick Street
G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # n/a and Contract # n/a
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SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
] Person [x]
] Publicly registered business corporation [ ]
] Privately held business corporation [ ]
] Sole proprietorship [ ]
] General partnership (Is
] Limited partnership
JTrust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
he 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:
California.
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 [x] No [ ] Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Ananthan Thanqavel Manager
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% of the Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
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limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Ananthan Thangavel See Section I.B. 100%
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? [ ] Yes [x] No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? [ ] Yes [x] No
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Not applicable.
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable
inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in
Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party?
[ ] Yes [x] No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
Not applicable.
SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount 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. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
None.
(Add sheets if necessary)
[x] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [x] 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 Not applicable.
FURTHER CERTIFICATIONS
1. [This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
2 . The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of 14
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those 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, state or local unit of government;
have not, during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 14
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
Ver.2017-1 Page 6 of 14
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. 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:
None.
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.
12. 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 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.
13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
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 MCC Section 2-32-455(b).
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 MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
Page 7 of 14
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
None.
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 FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ] Yes [x] No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes [x] No
If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
Not applicable.
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. If the Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:
Not applicable.
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.
Not applicable - the matter is not federally funded. A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
Not applicable - the matter is not federally funded.
(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, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2017-1 Page 9 of 14
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.
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 Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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. Not applicable - the matter is not federally funded.
Is the Disclosing Party the Applicant?
[ ]Yes [ ]No Not applicable - the matter is not federally funded
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 Not applicable - the matter is not federally funded
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No [ ] Reports not required
Not applicable - the matter is not federally funded
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ]Yes [ ]No Not applicable - the matter is not federally funded
If you checked "No" to question (1) or (2) above, please provide an explanation:
Not applicable.
Page 10 of 14
SECTION Vn - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
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 Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.cityofchicago.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 this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy 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 MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
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CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and Appendices A and B (if applicable), on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and Appendices A and B (if applicable), are true, accurate and complete as of the date furnished to the City.
Lakghmi Capital Management LLC
(Print or type exact legal name of Disclosing Party)
(Sign here)
Ananthan Thanqavel
(Print or type name of person signing)
Manager
(Print or type title of person signing)
Signed and sworn to before me on (date) October (fi 2017
NO.01AL6289S69
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ]Yes [x]No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to
which such person is connected; (3) the name and title of the elected city official or department head to
whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Not applicable.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
[ ] Yes [x] No
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 MCC Section 2-92-416?
[ ] Yes [ ] No [x] The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Not applicable.
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<¦ 335 Schiller LLC
1596.0000 3
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:
Lakshmi Capital All Weather Fund LP
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
[x] a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 335 Schiller LLC
OR
[ ] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 1907 n. Beverly Dr.
Beverly Hills, CA 90210
Telephone: (312) 610-1800 Fax: (312) 626-2414 Email: qdi@iattasiaw.com
Name of contact person: George Lattas
Federal Employer Identification No. (if you have one):
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Application for zoning map amendment (planned development) for:
335-345 West Schiller Street; 1355-1369 North Sedgwick Street
G. Which City agency Or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # n/a and Contract # n/a
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SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person [ ]
[ ] Publicly registered business corporation [ ]
[ ] Privately held business corporation [ ]
[ ] Sole proprietorship [ ]
[ ] General partnership (Is
[x] Limited partnership
[ ] Trust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation the not-for-profit corporation also a 501(c)(3))?
[ ]Yes [ ]No Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
Delaware.
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?
[x] Yes [ ] No [ ] Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Lakshmi Capital Management, LLC General Partner
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% of the Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
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limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Ananthan Thangavel See Section I.B. More than 7 . 5%
Lakshmi Capital Management, LLC See Section I.B. More than 7.5%
Thangavel Family Trust See Section I.B. More than 7 . 5%
No other entities own more than a 7.5% interest in the Applicant.
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? [ ] Yes [x] No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? [ ] Yes [x] No
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Not applicable.
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party? [ ]Yes [x]No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
Not applicable.
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount 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. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
None.
(Add sheets if necessary)
[x] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [x] 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 Not applicable.
FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of 14
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those 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, state or local unit of government;
have not, during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article 1 applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
Ver.2017-1 Page 6 of 14
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. 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:
None.
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.
12. 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 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.
13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
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 MCC Section 2-32-455(b).
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 MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
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If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
None.
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 FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ]Yes [x]No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ]Yes [x]No
If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
Not applicable.
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. If the Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:
Not applicable.
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. Not applicable - the matter is not federally funded. A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
Not applicable - the matter is not federally funded.
(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, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2017-1 Page 9 of 14
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.
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 Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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. Not applicable - the matter is not federally funded.
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No Not applicable - the matter is not federally funded
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 Not applicable - the matter is not federally funded
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No [ ] Reports not required
Not applicable - the matter is not federally funded
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No Not applicable - the matter is not federally funded
If you checked "No" to question (1) or (2) above, please provide an explanation:
Not applicable.
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SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
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 Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.citvofchicago.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 this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy 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 MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
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CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and Appendices A and B (if applicable), on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and Appendices A and B (if applicable), are true, accurate and complete as of the date furnished to the City.
Lakshmi Capital All Weather Fund LP
(Print or type exact legal name of Disclosing Party) By: Lakshmi Capital Management LLC, its General Partner By: Ananthan Thangavel, its Manager
By:
(Sign here)
Manager of Lakshmi Capital Management LLC
(Print or type title of person signing)
Signed and sworn to before me on (date) October \j> 2on
Notary Public
„ DOMENICAALBERO Notary Public, State of New Yorit
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [x] No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to
which such person is connected; (3) the name and title of the elected city official or department head to
whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Not applicable.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
[ ] Yes [x] No
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 MCC Section 2-92-416?
[ ] Yes [ ] No [x] The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Not applicable.
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335 Schiller LLC 1596.0000 4
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:
Thanqavel Family 2 006 Irrevocable Trust
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
[x] a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 335 Schiller LLC
OR
[ ] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 1907 n. Beverly Dr.
Beverly Hills, CA 90210
Telephone: (312) 610-1800 Fax: (312) 626-2414 Email: qdi@iattasiaw.com
Name of contact person: George Lattas
Federal Employer Identification No. (if you have one): n/a
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Application for zoning map amendment (planned development) for:
335-345 West Schiller Street; 1355-1369 North Sedgwick Street
Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # n/a and Contract # n/a
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SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person [ ]
[ ] Publicly registered business corporation [ ]
[ ] Privately held business corporation [ ]
[ ] Sole proprietorship [ ]
[ ] General partnership (Is
[ ] Limited partnership
[x] Trust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation the not-for-profit corporation also a 501(c)(3))?
[ ]Yes [ ]No Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
California.
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 [x] No [ ] Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Ananthan Thanqavel Trustee
Arul Thangavel Trustee
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% of the Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
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limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address
Ananthan Thangavel See Section I.B.
Arul Thangavel See Section I.B.
There are no other beneficiaries of the trust.
Percentage Interest in the Applicant
Undivided interest in trust.
Undivided interest in trust.
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? [ ] Yes [x] No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? [ ] Yes [x] No
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party? [ ]Yes [x]No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount 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. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
None.
(Add sheets if necessary)
[x] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [x] 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 Not applicable.
FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of 14
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those 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, state or local unit of government;
have not, during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
Ver.2017-1 Page 6 of 14
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. 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:
None.
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.
12. 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 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.
13. 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 $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
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 MCC Section 2-32-455(b).
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 MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
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If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
None.
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 FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ]Yes [x]No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ]Yes [x]No
If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
Not applicable.
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. If the Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:
Not applicable.
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.
Not applicable - the matter is not federally funded. A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
Not applicable - the matter is not federally funded.
(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, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2017-1 Page 9 of 14
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.
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 Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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. Not applicable - the matter is not federally funded.
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No Not applicable - the matter is not federally funded.
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 Not applicable - the matter is not federally funded.
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No [ ] Reports not required
Not applicable - the matter is not federally funded.
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ]Yes [ ]No Not applicable - the matter is not federally funded.
If you checked "No" to question (1) or (2) above, please provide an explanation:
Not applicable.
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SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
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 Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.citvofchicago.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 this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy 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 MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
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CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and Appendices A and B (if applicable), on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and Appendices A and B (if applicable), are true, accurate and complete as of the date furnished to the City.
Thangavel Family 2006 Irrevocable Trust (Print or type exact legal name of Disclosing Party)
By:
(Sign here)
Ananthan Thanqavel
(Print or type name of person signing)
Trustee
(Print or type title of person signing)
Signed and sworn to before me on (date) October {j 2017
Notary Public
Commission expires: c_,
Commission Expires September30,
D0MENICAAL3ER0
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any 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 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; 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% ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [x] No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to
which such person is connected; (3) the name and title of the elected city official or department head to
whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Not applicable.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
[ ]Yes [x]No
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 MCC Section 2-92-416?
[ ] Yes [ ] No [x] The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Not applicable.
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335 Schiller LLC 1596.0000 5
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Thanqavel Family Trust
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
[x] a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 335 Schiller LLC
OR
[ ] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 1907 n. Beverly Dr.
Beverly Hills, CA 90210
Telephone: (312) 610-1800 Fax: (312) 626-2414 Email: qdi@iattasiaw.com
Name Of contact person: George Lattas
Federal Employer Identification No. (if you have one): n/a
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Application for zoning map amendment (planned development) for:
335-345 West Schiller Street; 1355-1369 North Sedgwick Street
G. Which City agency Or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # n/a and Contract # n/a
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t
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person [ ] Limited liability company
[ ] Publicly registered business corporation [ ] Limited liability partnership
[ ] Privately held business corporation [ ] Joint venture
[ ] Sole proprietorship [ ] Not-for-profit corporation
[ ] Genera] partnership (Is the not-for-profit corporation also a 501(c)(3))?
[ ] Limited partnership [ ] Yes [ ] No
[x] Trust [ ] Other (please specify)
For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
California.
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 [x] No [ ] Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Muruqesa Thancravel Trustee
Krishnaveni Thangavel Trustee
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% of the Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
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limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Ananthan Thangavel See Section I.B. Undivided interest in trust.
Arul Thangavel See Section I.B. Undivided interest in trust.
There are no other beneficiaries of the trust.
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? [ ] Yes [x] No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month period following the date of this EDS? [ ] Yes [x]No
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party? [ ]Yes [x]No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount 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. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
None.
(Add sheets if necessary)
[x] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [x] 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 Not applicable.
FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
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The Disclosing Party and, if the Disclosing Party is a legal entity, all of those 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, state or local unit of government;
have not, during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
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contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. 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:
None.
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.
12. 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 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.
13. 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 $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
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 MCC Section 2-32-455(b).
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 MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
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If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
None.
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 FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ]Yes [x]No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ]Yes [x]No
If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
Not applicable.
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. If the Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:
Not applicable.
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.
Not applicable - the matter is not federally funded. A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
Not applicable - the matter is not federally funded.
(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, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
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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.
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 Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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. Not applicable - the matter is not federally funded.
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No Not applicable - the matter is not federally funded.
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 Not applicable - the matter is not federally funded.
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No [ ] Reports not required
Not applicable - the matter is not federally funded.
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ]YeS [ ]No Not applicable - the matter is not federally funded.
If you checked "No" to question (1) or (2) above, please provide an explanation:
Not applicable.
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SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
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 Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.citvofchicago.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 this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy 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 MCC Chapter 1-23, Article 1 (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
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CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and Appendices A and B (if applicable), on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and Appendices A and B (if applicable), are true, accurate and complete as of the date furnished to the City.
Thangavel Family Trust
(Print or type exact legal name of Disclosing Party)
' (Sign here) <
Murugesa Thangavel
(Print or type name of person signing)
Trustee
(Print or type title of person signing)
Signed and sworn to before me on (date) October 5, 2017
at County, (state).
SEE ATTACHED CALIFORNIA NOTARY PAGE (NEXT PAGE)
Notary Public
Commission expires:
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CALIFORNIA JURAT WITH AFFIANT STATEMENT
See Attached Document (Notary to cross out lines 1-6 below)
See Statement Below (Lines 1-6 to be completed only by document signerfs], nor Notary)
Signature of Document Signer No. 2 (if any)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of f/vS i>trCjeJ.€l
SARA NASSfUUlA Commiiiion# 21)6765 Notary Public - CatfontiB Lot Angtfcs County
Ot 14.2019
Subscribed and sworn to (or affirmed) before me
on this '-^ day of CO®V&C~ . 20fX.
by Date Month Year
(and (2) ),
Name(s) of Signerfs)
proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
SianatUre<:^S^X^ii ' Signature of Notary Public
Seal
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document.
Document Date:
Description of Attached Document
Title or Type of Document:
Number of Pages: Signers) Other Than Named Above:.
©2014 National Notary Association • www.NationalNotary.org • 1 -800-US NOTARY (1 -800-876-6827) Item #5910
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%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ]Yes [x]No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to
which such person is connected; (3) the name and title of the elected city official or department head to
whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Not applicable.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
[ ] Yes [x] No
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 MCC Section 2-92-416?
[ ] Yes [ ] No [x] The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Not applicable.
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