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This record contains private information, which has been redacted from public viewing.
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Type:
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Ordinance
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Status:
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Passed
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Title:
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Zoning Reclassification Map No. 2-E at 1136-1140 S Wabash Ave - App No. 18475
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Topic:
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ZONING RECLASSIFICATIONS - Map No. 2-E
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SUBSTITUTE ORDINANCE BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. That the Chicago Zoning Ordinance be amended by changing all the current DX-12 Downtown Mixed-Use District symbols and indications as shown on Map No. 2-E in the area bounded by: A line 216.98 feet north of East Roosevelt Road; South Wabash Avenue; a line 96.85 feet north of East Roosevelt Road; a line 105.00 feet west of South Wabash Avenue; East Roosevelt Road; a line 120.29 feet west of South Wabash Avenue; a line 96.12 feet north of East Roosevelt Road; and the Chicago Transit Authority Right-of-way to those of a Residential Business Planned Development which is hereby established in the area described above. SECTION 2. This Ordinance shall be in force and effect from and after its passage and due publication. Property Address: 1136 - 40 South Wabash Avenue/26 East Roosevelt Road RESIDENTI AL - BUSINESS PLANNED DEVELOPMENT STATEMENTS The area delineated herein as Planned Development Number , ("Planned Development") consists of approximately 21,557 square feet of property which is depicted on the attached Planned Development Boundary Map ("Property") and is owned or controlled by the Applicant, 1136 South Wabash, 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 ofthe Applicant's successors and assigns and, if different than the Applicant, the legal titleholder 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 ofthe 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 Plans. Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Departments of Planning and Development and Transportation. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval ofthe Department of Transportation. All work proposed in the public way must be designed and constructed in accordance with the Department of Transportation Construction Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by the Department of Transportation 4. This Plan of Development consists of sixteen (16) Statements: a Bulk Regulations Table; an Existing Land-Use Map; an Existing Zoning Map; a Planned Development Boundary Map; a Site/Landscape Plan; a Green Roof Plan and Building Elevations submitted herein. Full-sized copies of the Site Plan, Landscape Plan and Building Elevations are on file with the Department of Planning and Development. In any instance where a provision of this Planned Development conflicts' with the Chicago Building Code, the Building Code shall control. This Planned Development conforms to the intent and purpose of the Zoning Ordinance, and all requirements thereto, and satisfies the established criteria for approval as a APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 — 40 South Wabash Avenue/26 East Roosevelt Road INTRODUCTION DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 FINAL Planned Development. In case of a conflict between the terms of this Planned Development Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control. The following uses are permitted in the area delineated herein as a Residential Business Planned Development: Sub-Area A: Residential Units; day care, artist work or sales space, eating and drinking establishments, financial services (excluding payday loan stores and pawn shops), grocery and convenience stores, office, medical service, retail sales, wireless communication facility, consumer repair and laundry services, children's play center, personal service and accessory uses, including accessory parking. Sub-Area B: Retail, day care, artist work or sales space, eating and drinking establishments, financial services (excluding payday loan stores and pawn shops), grocery and convenience stores, office, medical service, retail sales, wireless communication facility, consumer repair and laundry services, children's play center, personal service and accessory uses In accord with Section 17-10-0503 ofthe Municipal Code, the Applicant may lease to members of the public on an hourly, daily, weekly or monthly basis up to forty-five percent (45%) of the minimum required parking spaces in Sub-Area A. On-Premise signs and temporary signs, such as construction and marketing signs, shall be pemiitted 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 ofthe Planned Development. For purposes of height measurement, the definitions in the Zoning Ordinance shall apply. The height of any building shall also be subject to height limitations, if any, established by the Federal Aviation Administration. The maximum permitted Floor Area Ratio ("FAR") for the site shall be in accordance with the attached Bulk Regulations Table. For the purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted Floor Area Ratio identified in the Bulk Regulations Table has been determined using a Net Site Area of 21,557 square feet and a base FAR of 12. The improvements to be constructed in Sub-Area A of the Property will utilize the following series of FAR bonuses: Description (list of all bonuses applied for and calculations) FAR Base FAR: Affordable Housing Bonus: Total FAR: APPLICAN T: 1136 South Wabash, LLC ADDRESS: 1136 - 40 South Wabash Avenue/26 East Roosevelt Road INTRODUCTION DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 Of this total FAR the building in subarca A is designed to an FAR of 12.84. 9. The Applicant acknowledges and agrees that the rezoning of the Property to this Planned Development triggers the requirements of Section 2-45-110 of the Municipal Code (the "2007 Affordable Requirements Ordinance" or the "2007 ARO"). The 2007 ARO provides that any developer of a "residential housing project" within the meaning ofthe 2007 ARO must: (i) develop affordable housing units as part ofthe project; (ii) pay a fee in lieu ofthe development of affordable housing units; or (iii) any combination of (i) and (ii). The Developer further acknowledges and agrees that the project has received an affordable housing floor area bonus, as set forth in the bonus worksheet attached hereto as Exhibit D ("Bonus Worksheet"), and as a result is also subject to the requirements of the former Section 17-4-1004-D ofthe Zoning Code (the "Density Bonus Provisions"). Like the 2007 ARO, the Density Bonus Provisions require on-site affordable housing or payment of a fee in lieu of providing affordable housing, but the formulas for calculating the number of required affordable units and the amount of the in lieu payment are different from the formulas in the 2007 ARO. If a project is subject to both the 2007 ARO and the Density Bonus Provisions, the developer may elect to comply with either. In this case, the Developer has elected to comply with the Density Bonus Provisions. In accordance with the formulas set forth in the former Section 17-4-I004-C and the Bonus Worksheet, the Developer must provide a minimum of 10,465 square feet of affordable housing floor area (the "Affordable Units") in the Planned Development, with an affordable unit mix comparable to the overall mix and approved by the Department's density bonus project manager, or make a cash payment in lieu of providing Affordable Units in the amount of $736,768.72 ("Cash Payment"). Prior to the issuance of any building permits for the Planned Development, including, without limitation, excavation or foundation permits, the Developer must either make the required Cash Payment or, if providing Affordable Units, provide a performance bond or other security in the amount of the Cash Payment ensuring construction of the Affordable Units. If the Developer elects to construct the Affordable Units, it must also enter into an affordable housing agreement with the City pursuant to the former Section 17-4-1004-E9 ("Affordable Housing Agreement") prior to the issuance of any building permits for the Planned Development, including, without limitation, excavation or foundation permits. The terms of the Affordable Housing Agreement and any amendments thereto are incorporated herein by this reference. The Developer acknowledges and agrees that the Affordable Housing Agreement will be recorded against the Property. The City shall execute partial releases of the Affordable Housing Agreement prior lo or at the time of the sale of each Affordable Unit to an income-eligible buyer at an affordable price, subject to the simultaneous execution and recording of a mortgage, restrictive covenant or similar instrument against such Affordable Unit. In addition to the Affordable Housing Agreement, the Applicant acknowledges and agrees that, pursuant to Section 17-4-1003-D3, the Bonus Worksheet will serve as an official record of bonuses and amenities. The Applicant must comply with the applicable affordable housing standards and requirements set forth in former Section 17-4-1004, the terms of which are incorporated herein by this reference. APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 - 40 South Wabash Avenue/26 East Roosevelt Road INTRODUCTION DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 PISV'S! OSjQ! JprTlflM FFJNAL The Applicant acknowledges and agrees that the sale of City-owned property at 1136-1140 South Wabash Avenue also triggered the requirements of the 2007 ARO. Pursuant to an ordinance adopted on April 15, 2015, the City and the Applicant entered into that certain Agreement for the Sale and Redevelopment of Land dated May 20, 2015, and recorded on June 19, 2015, as Document No. 1517044002 (the "RDA"). The RDA approves a 20-story building with 280 residential units, and requires the Applicant to provide 9,513 square feet of affordable floor area, or make a cash payment in the amount of $669,715.20. The Applicant is now proposing to construct a building with 320 units, which has increased the amount of affordable floor area to 10,465 square feet and the cash payment to $736,768.72, as set forth above. The Applicant acknowledges and agrees that (a) the affordable floor, area and cash payment required in this Planned Development shall replace and supersede the affordability requirements in the RDA, and (b) if this Planned Development does not receive City Council approval on or before July 13, 2016, any floor area that was not approved under the RDA will be subject to Section 2-45-115 ofthe Municipal Code (the "2015 ARO"). In such event, the Applicant shall meet with the Department of Planning and Development to determine the application of the 2015 ARO to the project, and the 2015 ARO requirements will replace and supersede the affordability requirements under the 2007 ARO with respect to the added floor area. Upon review and determination, "Part II Review", pursuant to Section 17-13-0610 of the Zoning Ordinance, a Part II Review Fee shall be assessed by the Department of Planning and Development. The fee, as determined by staff at the time, is final and binding on the Applicant and must be paid to the Department of Revenue prior to the issuance of any Part II approval. The Site and Landscape Plans shall be in substantial conformance with the Landscape Ordinance and any other corresponding regulations and guidelines. Final landscape plan review and approval will be by the Department of Planning and Development. Any interim reviews associated with site plan review or Part II reviews, are conditional until final Part II approval. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation, Environment and Buildings, under Section 13-32-125 of the Municipal Code, or any other provision of that Code. The terms and conditions of development under this Planned Development ordinance may be modified administratively, pursuant to section 17-13-0611-A of the Zoning Ordinance by the Zoning Administrator upon the application for such a modification by the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. . APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 - 40 South Wabash Avenue/26 East Roosevelt Road INTRODUCTION DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 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 Properly. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. The applicant has agreed to provide a 50% green roof over the net roof area and achieve LEED Certification to comply with the City of Chicago's Sustainable Matrix. This Planned Development shall be governed by Section 17-13-0612 ofthe Zoning Ordinance. Should this Planned Development ordinance lapse, the Commissioner ofthe Department of Planning and Development shall initiate a Zoning Map Amendment to rezone the property to a DX-12 Downtown Mixed-Use District. APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 - 40 South Wabash Avenue/26 East Roosevelt Road INTRODUCTION DATE: September 24, 201 5 PLAN COMMISSION DATE: May 19, 2016 FINAL FOR PUSLICATI RESIDENTIAL BUSINESS PLANNED DEVELOPMENT PLAN OF DEVELOPMENT BULK REGULATIONS AND DATA TABLE GROSS SITE AREA: Area remaining in the public right-of-way: Net Site Area: Sub-Area A: Sub-Area B: 28,759.1 1 sq. ft. (0.59 acres) 7,202.11 sq. ft. (0.16 acres) 21,557(0.49 acres) 19,600 sq. ft. 1,957 sq. ft. Sub-Area A: Sub-Area B: 12.84 12.00 Overall FAR: SETBACKS FROM PROPERTY LINE Sub-Area A Wabash Street: North Property Line: Holden Court: South Property Line: Sub-Area B East Property Line: North Property Line: West Property Line: Roosevelt Road: None None None None None 10 ft. None None MAXIMUM NUMBER OF UNITS: Sub-Area A: Sub-Area B: 320 0 MIN. NO. OF ACCESSORY OFF-STRMEET PARKING: Sub-Area A: Sub-Area B: 142 0 MINIMUM BICYCLE PARKING: MINIMUM NUMBER OF OFF-STREET LOADING: Sub-Area A: Sub-Area B: One berth (10'x25') 0 MAXIMUM BUILDING HEIGHT: Sub-Area A: Sub-Area B: 303 feet 6 inches 20 feet (existing) APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136-40 South Wabash Avenue/26 East Roosevelt Road INTRODUCTION DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 >t m floss.-' '•• —aa®^—r- U j ,'_ . dHHIVI ¦ .•. .7t,:;::i-.--.-t;:t/.i"-.--:'-.= 1—— |109|. icKgg), ¦¦ 1 1 r- i- -. . IfUBRI' r ¦ ¦¦¦¦¦ 1 | - - .... J :— i |109|-., ...V:.--- V.' } i | : :,,...„:¦¦ . , ..... 1 1 l |1010|PI PD !l69 ¦S3, S0;, I: 35- s-S?: Copyright (c) 2011 Zoning data rertacts all ordinances passed;R,QjGtSEjy.E-LrTiR\Dj bin (he most recent Gitv Council masting . Cily ot Chicago EXISTING ZONING MAP APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 - 40 S. Wabash Ave./26 E. Roosevelt Rd. INTRO DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 - 40 S. Wabash Ave./26 E. Roosevelt Rd. INTRO DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 Fl! i u urn '/UtfUUM *v« * ~ ¦ t-'iV -f?iJ ^w-1 " ""' -v E ROOSEVELT ROAD PLANNED DEVELOPMENT BOUNDARY MAP APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 - 40 S. Wabash Ave./26 E. Roosevelt Rd. INTRO DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 E. ROOSEVELT RD. TWO WAY TRAFFIC SITE PLAN / LANDSCAPE PLAN o~™""mT £f) Applicant: 1136 South Wabash, LLC Address: 1136 South Wabash Ave. Introduced: TBD © 2016 Solomon Cordwell Buonz Plan Commission: May 19, 2016 Gross Roof Area: Net Roof Area: Total Green Roof Area: 18,948 sf 15,677 sf 7,861 sf (50.1% of Net Roof Area) Green Roof Area u it —i < O 5 x o CO? O Green Roof 980 sf LU > - - u_ ^ < CO 1- m < < 5 co ^ GREEN ROOF PLAN APPLICANT: 1136 South Wabash, LLC ADDRESS: 1136 - 40 S. Wabash Ave./26 E. Roosevelt Rd. INTRO DATE: September 24, 2015 PLAN COMMISSION DATE: May 19, 2016 ELASTOMERIC COATED CONCRETE COLUMNS PERFORATED METAL GARAGE CLADDING WITH METAL SUBFRAME ELASTOMERIC COATED CONCRETE WALL WITH ARCHITECTURAL REVEALS ALUMINUM AND GLASS CURTAIN WALL SYSTEM WITH SHADOW BOX AND INTERNAL LIGHTING BACKLIT SIGNAGE PREFABRICATED METAL SUNSHADE ALUMINUM CURTAIN WALL STOREFRONT SYSTEM WITH INSULATING GLASS OVERHEAD METAL AND GLASS SECTIONAL GARAGE DOOR GLASS RAILING ALUMINUM FRAME WINDOW WALL SYSTEM WITH INSULATING GLASS INSULATED EXTRUDED SLAB EDGE COVER METAL BALCONY RAILING SYSTEM WITH GLASS INFILL SOLID ARCHITECTURAL CLADDING SYNTHETIC PLASTER PAINTED MASONRY WALL METAL CANOPY _. | |~T 10 RESIDENTIAL FLOORS @ 9'-5 I" 12 1 RESIDENTIAL PRV FLOOR @ lO'-ll {" 9 RESIDENTIAL FLOORS @ 9'-5 3" AREA COVERED WITH ADJACENT BUILDING NORTH ELEVATION rT"~T Applicant: 1136 South Wabash, LLC Address: 1136 - 40 South Wabash Ave./26 E. Roosevelt Rd. Introduced: September 24, 2015 © 2016 Solomon Cordwell Buenz Plan Commission: May 19, 2016|101010101010101010 10 10|11 12 13 14 15 16 KM \JELASTOMERIC COATED CONCRETE COLUMNS ' 'l vt PERFORATED METAL GARAGE CLADDING WITH METAL SUBFRAME ELASTOMERIC COATED CONCRETE WALL WITH ARCHITECTURAL REVEALS ALUMINUM AND GLASS CURTAIN WALL SYSTEM WITH SHADOW BOX AND INTERNAL LIGHTING BACKLIT SIGNAGE PREFABRICATED METAL SUNSHADE ALUMINUM CURTAIN WALL STOREFRONT SYSTEM WITH INSULATING GLASS OVERHEAD METAL AND GLASS SECTIONAL GARAGE DOOR GLASS RAILING ALUMINUM FRAME WINDOW WALL SYSTEM WITH INSULATING GLASS INSULATED EXTRUDED SLAB EDGE COVER METAL BALCONY RAILING SYSTEM WITH GLASS INFILL SOLID ARCHITECTURAL CLADDING SYNTHETIC PLASTER PAINTED MASONRY WALL METAL CANOPY ^|910|13 10 RESIDENTIAL FLOORS @ 9'-5 I" t lIIO 1 RESIDENTIAL PRV FLOOR @ lO'-ll j" 9 RESIDENTIAL FLOORS @ 9'-5 5" ED 35 pa rMHJzLU_IiX ZEE m |10 9|25' 50' 1136 South Wabash, LLC 1136 - 40 South Wabash Ave./26 E. Roosevelt Rd. Introduced: September 24, 2015 Plan Commission: May 19, 2016 ELASTOMERIC COATED CONCRETE COLUMNS PERFORATED METAL GARAGE CLADDING WITH METAL SUBFRAME ELASTOMERIC COATED CONCRETE WALL WITH ARCHITECTURAL REVEALS ALUMINUM AND GLASS CURTAIN WALL SYSTEM WITH SHADOW BOX AND INTERNAL LIGHTING BACKLIT SIGNAGE PREFABRICATED METAL SUNSHADE ALUMINUM CURTAIN WALL STOREFRONT SYSTEM WITH INSULATING GLASS OVERHEAD METAL AND GLASS SECTIONAL GARAGE DOOR GLASS RAILING ALUMINUM FRAME WINDOW WALL SYSTEM WITH INSULATING GLASS INSULATED EXTRUDED SLAB EDGE COVER- METAL BALCONY RAILING SYSTEM WITH GLASS INFILL SOLID ARCHITECTURAL CLADDING SYNTHETIC PLASTER PAINTED MASONRY WALL METAL CANOPY SOUTH ELEVATION Applicant: Address:|10 9|25' 50' 1136 South Wabash, LLC 1136 - 40 South Wabash Ave./26 E. Roosevelt Rd. Introduced: September 24, 2015 Plan Commission: May 19, 2016 ELASTOMERIC COATED CONCRETE COLUMNS PERFORATED METAL GARAGE CLADDING WITH METAL SUBFRAME ELASTOMERIC COATED CONCRETE WALL WITH ARCHITECTURAL REVEALS ALUMINUM AND GLASS CURTAIN WALL SYSTEM WITH SHADOW BOX AND INTERNAL LIGHTING BACKLIT SIGNAGE PREFABRICATED METAL SUNSHADE ALUMINUM CURTAIN WALL STOREFRONT SYSTEM WITH INSULATING GLASS OVERHEAD METAL AND GLASS SECTIONAL GARAGE DOOR GLASS RAILING ALUMINUM FRAME WINDOW WALL SYSTEM WITH INSULATING GLASS INSULATED EXTRUDED SLAB EDGE COVER METAL BALCONY RAILING SYSTEM WITH GLASS INFILL SOLID ARCHITECTURAL CLADDING SYNTHETIC PLASTER PAINTED MASONRY WALL METAL CANOPY EAST ELEVATION Applicant: Address: 1136 South Wabash, LLC 1136 South Wabash Ave. Introduced: TBD Plan Commission: May 19, 2016 Department of Planning and Development CITY OF CHICAGO MEMORANDUM Alderman Daniel S. Solis Chairman, City Council Committee on Zoning David L. Reffman Secretary Chicago Plan Commission May 20, 2016 RE: Proposed Planned Development for property generally located at 1136-40 South Wabash Avenue. On May 19, 2016, the Chicago Plan Commission recommended approval ofthe proposed planned development submitted by 1136 South Wabash, LLC. A copy ofthe proposed planned development is attached. I would very much appreciate your assistance in having this introduced at the next possible City Council Committee on Zoning hearing. Also enclosed is a copy ofthe staff report to the Plan Commission which includes the Department of Planning and Development, bureau of Planning and Zoning recommendation and a copy of the Resolution. If you have any questions in this regard, please do not hesitate to contact me at 744-5777. cc: Steve Valenziano PD Master File (Original PD, copy of memo) 121 NORTH LASALLE STREET, ROOM 1000, CHICAGO, ILLINOIS 60602 REPORT TO THE CHICAGO PLAN COMMISSION FROM THE DEPARTMENT OF PLANNING AND DEVELOPMENT FOR APPROVAL: APPLICANT: LOCATION: MAY 19, 2016 RESIDENTIAL BUSINESS PLANNED DEVELOPMENT 1136 SOUTH WABASH, LLC 1136 S. WABASH AVE. AND 26 E. ROOSEVELT RD. Pursuant to the provisions of the Chicago Zoning Ordinance, Title 17 of the Municipal Code of Chicago, the Department of Planning and Development hereby submit this report and recommendation on a proposed Residential Business Planned Development for your review and recommendation to the Chicago City Council. The application for the amendment to the Chicago Zoning Ordinance was introduced into the City Council on September 24, 2015. Proper legal notice ofthe public hearing on the application was published in the Chicago Sun Times on May 4, 2016. The Applicant was separately notified of this hearing. This application is submitted as a mandatory planned development pursuant to section 17-8-0512-Tall Buildings which, requires planned development review and approval for any building in a DX-12 Zoning District that meets or exceeds 220 feet. SITE AND AREA DESCRIPTION The project consists of a rectangular shaped lot containing a total of 21,557 square feet and is bounded on the north by a 2-story commercial building, on the east by South Wabash Avenue, on the south by single story commercial building and East Roosevelt Road, and on the west by 2. Existing Zoning Map 1. Planned Development Boundary Map a public alley. PROJECT DESCRIPTION AND BUILDING DESIGN The applicant proposes to rezone the site from a DX-12 (Downtown Mixed-Use District) to a Residential Business Planned Development and establish two sub areas. Subarea A will allow for a 26-story mixed-use building with ground floor retail, 320 residential units, 142 accessory parking spaces and accessory uses. Subarea B is improved with a one-story commercial building and will remain. 3. Existing conditions - Wabash Ave. 4. Existing Conditions - Roosevelt Road. The 26-story residential apartment building fronts South Wabash Avenue. The tower portion of the building is defined by an architectural window system and metal panel system. The ground floor contains the retail area and the residential entrance lobby. Floors two through four contain four levels of accessory parking and are screened from the public view via a perforate panel system. The perforated metal panel system includes two color tones to more effectively reduce the massing ofthe base of the building. 5. Renderings ACCESS/CIRCULATION Access for vehicular traffic is provided via a proposed curb cut along South Wabash Street and leads to 142-accessory parking spaces and 50 bike parking spaces. The public alley allows access to (2) 10'x 25' loading berths for the retail and residential uses. Access for pedestrians to the residential and retail occur along South Wabash Avenue. The entrance for residential patrons is also defined by a metal canopy. LANDSCAPING and SUSTAINABILITY The applicant must comply with the City of Chicago's Landscape Ordinance. In addition the proposed building is required to achieve building certification and provide a 50% green,roof as defined by the City of Chicago Sustainable Matrix. Gross Roof Area: Net Roof Area: Total Green Roof Area: 18,943 sf 15,677 sf 7,861 sf (50.1% of Net Roof Area) Green Roof Area 7. Green Roof Plan BULK/USE/DENSITY Reference attached Bulk and Data Table Exhibit. RECOMMENDATION The Department of Planning and Development has reviewed the project materials submitted by the Applicant and have concluded that the proposed development would be appropriate for the site for the following reasons: The project complies with the Standards and Guidelines for Planned Developments in the Zoning Ordinance (Section 17-8-0900). 17-3-0400 Bulk and Density standards. The proposed Planned Development allows for 12.0 FAR and the applicant is paying $ 736,768.72 for 1.48 FAR via the Affordable Housing Opportunity Fund. The site is currently zoned DX-12 (Downtown Mixed-Use District) and permits an FAR of 12. The planned development via the additional 1.48 FAR bonus shall permit an overall 13.48 FAR. This project will have similar uses as the surrounding areas, which include lodging, residential, commercial and retail uses, and accessory parking spaces. 17-8-0908 Green Design: The proposed building shall be required to achieve building certification and provide a 50% Green Roof over the net roof area to satisfy the requirements of the City of Chicago's Sustainable Guidelines. 17-8-0905 Pedestrian Orientation: Primary pedestrian entrances are located at the sidewalk level and allow unimpeded pedestrian flow along S. Wabash Avenue. Furthermore the entire street frontage of the building along S. Wabash Avenue is enlivened by a storefront window system looking directly onto the street. 17-8-0904 Transportation, Traffic, Circulation and Parking: Motor vehicle parking would be accessed from S. Wabash Avenue and an overhead door leading to a ramp allows vehicular traffic into the parking levels. The parking will be screened via a series of perforated metal panels with articulated features and at least two different color tones. 17-8-0901 Use, Bulk, Density and Intensity: The proposed development is compatible with the character of the surrounding area in terms of uses, density, and building scale. The proposed Planned Development would be consistent in bulk, density, and Floor Area Ratio (F.A.R.) with the surrounding area. The height ofthe proposed 26-story (303' 6") building will be consistent and is within the context ofthe surrounding area. Based on the foregoing, it is the recommendation of the Department of Planning and Development that the revised application for a Residential Business Planned Development be approved and that the recommendation to the City Council Committee on Zoning, Landmarks and Building Standards is: "As Amended, Passage Recommended." Department of Planning and Development DEPARTMENT of PLANNING and DEVELOPMENT CITY OF CHICAGO RESOLUTION RESIDENTIAL BUSINESSS PLANNED DEVELOPMENT 1136 SOUTH WABASH AVENUE 26 EAST ROOSEVELT ROAD WHEREAS, the applicant, 1136 South Wabash, LLC, proposes to rezone the site from a DX-12 (Downtown Mixed-Use District) to a Residential Business Planned Development. The proposal will establish a 26-story high-rise mixed use building with 320 dwelling units, include commercial and retail uses at the ground floor, accessory parking and accessory uses; and WHEREAS, This development is being submitted by the applicant as a mandatory planned development application pursuant to section 17-8-0512-Tall Buildings which, requires planned development review and approval for any building in a DX-12 Zoning District that meets or exceeds 220 feet and an application for a Planned Development was introduced to the City Council on September 24, 2015; and WHEREAS, proper legal notice of the hearing before the Chicago Plan Commission was published in the Chicago Sun-Times on May 4, 2016. The proposed Zoning Application was considered at a public hearing by this Plan Commission on May 19, 2016. The Applicant was separately notified of this hearing; and WHEREAS, the Plan Commission has reviewed the applications with respect to the provisions of the Chicago Zoning Ordinance and finds that the proposal will be consistent with said provisions; and WHEREAS, the Department of Planning and Development recommended approval of the application, with the recommendation and explanation contained in the written report dated May 19, 2016, a copy of which is attached hereto and made a part hereof; and WHEREAS, the Chicago Plan Commission has fully reviewed the application and all informational submissions associated with the proposed amendment, the . report and recommendation of the Commissioner of the Department , of Planning and Development, and all other testimony presented at the public hearing held on May 19, 2016 giving due and proper consideration to the Chicago Zoning Ordinance; and 121 NORTH LASALLE STREET, ROOM 1000, CHICAGO ILLINOIS 60602 DRAFT NOW, THEREFORE, BE IT RESOLVED BY THE CHICAGO PLAN COMMISSION: THAT the final application dated May 19, 2016 be approved as being in conformance with the provisions, terms and conditions of the corresponding Zoning application; and THAT this Plan Commission recommends approval to the City Council Committee on Zoning, Landmarks and Building Standards of the final zoning application dated May 19, 2016; and THAT the above-stated recitals to this resolution together with the report of the Commissioner of the Department of Planning and Development be adopted as the findings of fact of the Chicago Plan Commission regarding the zoning map amendment for a Residential Business Planned Development application. Martin Cabrera, Jr. / Chairman Chicago Plan Commission Approved: May 19, 2016 RBPD No. RECEIVED AMENDED MAY 1 9 201* CITY OF CHICAGO Initial: ^\f\}^AjL-U^ APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE ADDRESS of the property Applicant is seeking to rezone: 1136 - 40 South Wabash Avenue/26 E. Roosevelt Road Ward Number that property is located in: 4^ APPLICANT 1136 South Wabash. LLC ADDRESS 30 E. Roosevelt Road CITY Chicago STATE IL ZIP CODE 60605 PHONE 312-327-3350 CONTACT PERSON Michael Ezgur Is the Applicant the owner ofthe property? YES NO X 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 applicant to proceed. OWNER City of Chicago 726 E. Roosevelt, LLC ADDRESS 121 N. LaSalle Street/1456 Ridge Road CITY Chicago/Highland Park STATE IL/IL ZIP CODE 60602/60035 PHONE 312-744-4477/312-636-6937 CONTACT PERSON Michelle Nolan/Rolando Acosta If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information: ATTORNEY Rolando R. Acosta ADDRESS 1030 W. Chicago Ave CITY Chicago STATE PHONE 312-636-6937 IL ZIP CODE 60642 FAX 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. Keith Giles, Christine Skolnick On what date did the owner acquire legal title to the subject property? _ Has the present owner previously rezoned this property? If Yes, when? No Present Zoning District: DX-12 . Proposed Zoning District: RBPD Lot Size in square feet (or dimensions): 21,557 s.f. Current Use ofthe property: Surface parking lot and one story commercial building with no parking Reason for rezoning the property: Redevelopment of the Property 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): Development of a 26 - story, 303.5 feet tall, mixed-use building, consisting of approximately 5,000 sq. ft. of ground floor retail space, 320 residential dwelling units. 142 parking spaces and one loading berth; the existing one-story commercial building with no parking will remain On May 14lh, 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size ofthe project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information) YES X NO rv\J CITY OF CHICAGO KCONOM IC f) ISCLOST.l ll K STATEM KiS'T ANT) AFJTDAVT T skction i - <;f\fral in formation A. Legal name ofthe Disclosing Parly submini:^ this HDS. Include d/b/a/if applicable Sct Check ONF of flic following flirt c boxes: Indicate -.vhetber the Disclosing Party subiniJiirji; this EDS is: | j the Appliesm OR [>d 2 legal entity holding a direct or indirect interest in the Applicant. Slate the legal name ofthe Applicant in which the Disclosing Parly holds an interest: ii;t/>Soiciii WalaOi.jjj: OR ~" " 3. j 1 a legal cmily with a rijUit of control (set Section Si ILL) State the kgi:l name of the entity in which the Disclosing Parly holds a right of control: B. business address of the Disclosing Party: 163 N. Q;irfc Sl. Suia- 4W» Email: _mimd<&Arx^jiif£tir.cc>m D. Name of contact person: RoLanlo R. Aoas-a El. Federal Employer Identification No. (if you have one): F. BricFdcscnplian of contract, transaction orochcr undertaking (inferred lo hc.'ow as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable): Warned »cvckp„,uti l<>r 1I36 - 40S. \V-jhujJi/26 li. Reoscvett Rd G. Which City agency or department is requesting this FT>S ? DPD tithe Matter is a contract being handled by the City's Department of IVociircmatt Services, please complete the following: Specification H and Contract % Parx i of r> - ftl.SCl.OSfiMK OK OWN .SK:>Hi:v !;\ i EiifSVS A. NATUKi; Ov T:iK i)5SCi.O$LNO f'AKTV i. ir>dk-;Us: the stature o?"she Disclosing Psrtv: [ ) Pcrsou ' j Limited liability company' [J Publicly registered busings coqjorattor. ! | Litni'.-c-d liability pail&ership > I Privately held business corporation | 1 Joint venture [] Sole proprietorship { ] No*-ior-pioTit corpo rat to: i ? 1 General partnership fls the not-fo!-profit corporation aiso a 50l(c}(!))>? { | Limited partnership \ ) Ye* I } Vo k) Tnwc i] Other (please specify) ; For lc*.;-al endues, the state (or foreign country) of incorporation, or organization, if applicable: tllutois; }. .For legal entities not organized in the State of UKiujiv.: Has :h« of jani-Aaiion registered to do holiness in the State oniiinois as a foreign entity'.' I j Yes f j No fx? V/A B. IF TUP. DISCLOSING PARTY ISA LliOAL S-NTITY: 1. List bciow the full name; and rides of all executive officers and ail directors of the entity. MOTE: For not-for-profit corporations, also fiss-i below all members;, if any* which ace. legal entities. If there arc no such tnendiei's, write "no members." For trust::. estates or other similar entities, list below the legal dilcboldcrfs). If (neemily is a f'«aerar patfitcrship. limited psctnerchip* Inn tied liability company, limited liability partnership or joint venture* list below the name and title of each general fi.-jrlr.er . managing member, manager or any other person or entity that controls the day-io-dsy management of the Disclosing Patty. NOTE: F.:tcb legal entity listed bclo* roust swbini! an P.DS.un i:s own behalf.
Name. Title
AtlK I-:. Sco;i 'Jiustce
2. please provide tire following information concerning each person or entity having u dixect ur indirect beneficial iniercst (iticluding ownership) in excess of 7.5% of the Disclosing Party, F.xsmplcs of.such an intercut include shares in a corporation, partnership interest in a partnership or joint veni««j.
Page 2 of 13
interest of a member or managerin a limited liability comparty. or interest os' a beneficiary *;!":• trjst. ««ijic or o'turr similar entity, i; none, state "None." N'QTIi: i'ursuani to Section 2 f .S^-OHO of the Mnntci'.vtl (.'ode oi'OMc;;:;g f'Mui-icipal Code"), ihe Cil;. may require any such tulcKionai information from any applicant which i*- reasonably i mended to achieve fiii! di.cciosunr.
i-'crcema^c buercs: it; itiv Disci osirrir I'actv
Julis L Soju. IM K. <.•&:?>.St *v«H). :~b:^ivvv ll.oObtti ItttVi
SECTION IU - BUSINESS RELATIONSHIPS WfTH CITV EL-KCTED OFFICIALS
Has the Disc'ioiing. Party hao" a "business relationship," a.s defined in Chapter of the Municipal
Code, wilh any City ejected official iii the 12 months before the da:c this EDS is signed'?
j I Yes
If yes. piea.tc identify bcJovv die ti;»ne(s> ofsuch City elected officials) and describe such nclalions&ipfsl:
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHEK RETAINED PARTIES
Ti;c Disclosing party must disclose the name and business address of csch subcouiraclo?. attorney, lobbyist, accountant, consultant and any other pe,:.«n or entity whom the Disclosing Party has retained or expects to retain in connection with the Waller, 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 co disclose employees who are paid solely through thc-Dwelostug Party's regular payroll.
"Lobbyist" means any pe.son or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (t) ». not-for-profit entity, on an unpaid basis, os p.) himself. "Lobbyist" also meatus any person or entity any part of whose duties us an employee of another includes undcTtiiJcwy to influence any legislative or administrative action.
If the Disclosing;. Party is uncertain whether a di.tclOin.trc required under this Section, the Disclosing Patty must either ask the City whether disclosure is required or make the disclosure.
PspX. of !3
N'anic (indicate whether (tusinuss Relationship to Disc losing t'rtrty i-Vus (indicate v.-hethe:
rcu.-.acd or anticipates Addteus (.subcortU&elor. attorney, paid or e-stirentcd.i NOTE:
¦x> h>i: retained? lobbyist, cii: i ¦¦hnur'y rate" m '; .b.d. " ts
no; eji acceptable response.
; Add sheets if necessary>
\<\ <*iwtck hero jf the Disc losing Party has noi retained, nor expects to retain, any such persons or entities. SECTION V - CiiRTlFICATrONS
A. COURT-ORDER Rf> CHI.1-D SUPPORT COM PU A NCI£
Under Municipal Code Scclioa 2-9'.'.-+\5. substantia! owner* of business cotitics tftat contract witli the City must r<:waia in compliance; with '.hei; child support oblivions tltrrmrihout the contract's terwi.
lias any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
f J Yes [>rj No lJ.N.VJ«^P-.?UfyS|tU.y OJ iu.diisc.lly ; owns 10% o* tnoic of thc-
Disclosing Party.
if "Yes," has the person entered into a court-approved sgrcciatent for payment of ;>Ji ssrpport owed and is tin: person hi compliance with that agreement?
I I Yes ( j No
». MiRTI{GR CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1»23. Article 1 ("Article P'flwbich the Applicant should consult for defined terms (e.g., "doing business"') and legal requirertieuis), if the Disc-losing Party ttsbrtiittiny (his EOS is the Applicant and is doing business with the City, then the Disclosing Party certifies as folio'-vs: (i) neither the Applicant nor any controlling person is currently indicted or charged w ith. 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 on ofltccr or cuipfoyoc of the City or a ;;.y sister agency; and
Pase & of t!;
.;. i iif Disclosing i'a"y ::i;k!. if'.i'ts: Disciosin;: Party i.-: ¦;. leg.';! >;:i;:i!y. nii of ihose piM-rvms or eit'.iiics Kif.'iijficii ii: Sector) ii ci.'. ol"this L-.DK:
:;. ;:rc not presently debarred. suspended, prop::?.:;:; for debarment, declared im'-'igiblr or volun airily excluded f:oro ?si\ transactions by any federal, state or local unit cf government*.
have not, wtthtn a fcv<;.ycar period. preceding lh.xii convicted of a. criminal offense. adjudged guilty, or had a civil iudgnicnt rendered against them in connection wilh: obtainiiiL' attempting to '.jbtain. or performing ;i public (federal, s'.v.:-,: or lnc:d) tru'.vtf.ciioa or toiiiract under public transaction: a violation of federal or stale antitrust stinut-es: fraud; cmlscy-vdcmeut: fheft: forgery; bribery: falsif.ealicn or destruction of records: making false sUMe-mcnts: or receiving stolen property;.
arc not presently indicscd for. or criminally ft civilly charged by, a governmental entity (fedent), stale or local) with committing any ofthe. offenses set forth in clause 13.2.1). of this Si'dton V;
have not. within a five-year period prccedim: the date of this IIIXS, Jiad one or more public ironsactions (federal, state or local) terminated for cause or default: and
have not within a five-year period preceding the date of Ibis HDS, been convicted, adjudged gesity. or found liable iii a civil proceeding, or in :my criminal or civil action, tctcludinu actions concerning caviroiujtcaia! violations, in-astutrd by the City of by Use federal government, any state, or any other unit of local govejnjnent.
3. The certifications in subparts 3.4 and. 5 concern:
• the Disclosing Party;
? any "Contractor" (meaning any eonlractor or subcontractor used by the Disclosing Party in connection wilh the Mailer, including but i»o! limited to all persons or legal entities disclosed under Section IV, "Disclosere of Subcontractors and Oliver Retained Parties");'
* any "Affiliated IvnUty" (meaning a person or entity that, directly or indirectly; controls the Disclosing Party, is controlled by the Disclosing Pa.cty. or is. with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking manstgemcttt or ownership: identity of interests among family members, shared facilities and equipment: common use of employees; or orgmiiznuon of a business entity following the ineligibility of a business cotity to do business with federal or suite or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entisy); with respect to Contractors, the tetni Affiliated Entity means a person or entity that directly or indiiccJiy controls the Contractor, is controlled by it, or. with the Contractor, is under common control of another person ot entity;
* any responsible official of the Disclosing Party, any Contractor or :s«y AITiiiiiied t-jui.y or any otbe.r official, agent or employee of ihe 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").
Neither iii* l/lscJc-s';.'!'-:. I'.-iriy. ?K»r- :i;iy f .'otl(.• ;ttor. nor ::::.y A iTjiiViUro* v"n!tty uf cither ;f:e iJiscb'-'ifo.; ''anv •.it any • .;/;ur;:iir:i ne? any Agents have, during the, five yea-.a before die date ih«s f;DS is signed, or. u-ii.h respect u~> a Contractu*. ;tn Affiltaied Hn»iiy. or an Affiliated iimity of a C:>r.iiracu«: d-.-rmc the five years before ihe date of such Contractors or Afnfjatat! £n lily's extract or engagc-meni. in connection with the
Di ibc:.; or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, (he St aw of !:!i*;i>i,s. or any agency of the federal govcrmueni orof.oiy stale or ,'ocal-t'.ovcmmcnr. in the tinned .States of America, in that officer's
or ;:iupi'uyec's nMiciai capacity:
h. agreed o* eoilud'cd wiih other bidders* or piospcc'.ivc hidders. or beer, a pany 10 any seel: at-rcfctiicni. or bean convicted or adjudged guiky of agree men; or collusion among bidders o: prospective bidders, in •ostrainl of freedom of Cora petit ion by agxceutunl to bid a fixed price oi
Otherwise; o:
made en adti-isstoa ol --och conduct described tn a. o; b. above that is a matter of record, but have not been prosecuted foe Such conduct.-, or
violated the provisions of Municipal Code Section 2-0'2-fi i 0 {Living Wage Oiduntncc).
'! Neither the DLschssing Party. Affiliated JSpitty or Couttaciar, 01 any of their employees, of fie tub;, agents or partners, is barred from contracting with any unit of stave or local jiovemmt-nt a-;: a result of engaging in or being convicted of (I) bid-rigging in violation of 7 20 ILCS 5/33«:-3; (?.) bid-roiaJiug in violation of -7-20 ILCS 5/i>ri--imy si tni la? o'ffejisc of¥hy siaitToj"oHfiFf JmTcTState«i of America that contains the same elements; as the offense of bid-rigging or btd-rotaimg.
Neither the Disclosing Party nor any Affiliated Eatity is Itsled on any of the following lists maintained by die Office of Foreign Assets Control of the U.S. Department of the Treasury or the Darcau of Industry and Security of the U.S. Department of Commerce or their successor'.*: the Specially Designated Nationals List, the Dented persons List, (he Unverified List, she Entity List and the Debarred List.
The Disclosing Party understands and shall comply wilh the applicable requirements of Chapters 2-55 (Legislative Inspector Cicnettil), 2-56 (Inspector General) and 2-!56 (Covcrnmcnlal Ltheesl of f?te Municipal Code.
If the Disclosing Party is unabb no certify to any ofthe above statements i" this Pan K (Kurlhct Certifications), the Disclosing Party must explain below
iLti-.r ictters "NA." the word "N'onc." or no K-sponfe p<:iiiv <« the Siuc-s above, it will K* co*:efu$:vcly «>:e:.-f.r-;c\i '.!-:vi the Dlscios :••.>: !'r.r.v ecnsficd ro die above sin;ci»or.:s.
S. To ihe !>>.-s? a''*he Disclosing Party':; Rnowttdgc afics tessoriablc inquiry, the fntiuwing is a complete list ot'a.'r current ernplo-yctj; ofthe Disclosing I'arty who were, at any time durmg ihe 12-inonth period preceding t.he cteculion date of this LiDS. a a employee, or ejected or appointed official.
of die City of Chicago (if rm;:e. indicsue wit!: "N/A" m ""nonr' K
K'ons
9. To the btjtt ofthe Disclosing Party's knowledge after reasonable inquiry, the folio win*- is a complete Its; of all gifts that the Disclosing Party has given u: caused to be giveo, at any time during the 12-nioisth period preceding the execution date of this EDS, to nn employee, or elected cr appointed official, of the City of Chicago. For purposes' ofihis: statement, u "gift" docs not include: (») anything made •ccnctrally available to Ci ty employes;:; or to the general public, or of"official City business aad having a sctail value of less than $20 per recipient fif none, indicate wilh "N/A" or "none""). As to any gift listed below, please also I is: the name of the City recipient.
None?
C. CERTIFICATION OP STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (eheel: one)
[ J is M is not
a "finunctfil institution* as defined in Section 2-32-4 $S(b| of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges;
"We are not and will not become a predatory lender as defined ;n Chapter 2-3?. ofthe Municipal Code. Wc further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. Wc understand that becoming a predatory iender or becoming an nffiliale of t> predatory lender snay result in the lo.ss ofthe privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined tn Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Cltapier ?. ;<2 of the Municipal Code, explain here (attach additional pages if necessary):
Page 7 of CI
If ihe letters "NA." the word "Noni;." or no response siop-cars on :he lirses above. •: w\r be conclusively pre.-iutned that the Disclosing i'':tity certified (o the. above stalecactus.
D. CURTi:-"lCA flON HOARDING INTF.lt CS'f IN CITY BUSINESS
Any svoru.s or terms thai aie defined in Chapter 2-i 56 ofthe- Municipal Co<1e have the same meanings when used in this Pars 0.
In accordance with Section 2-i i6"-l !0 of t«c Munietpal Code: Docs any official or employee ofthe City have n financial, interest in his or her own R-.-me or ua the name of any sine-: pcz-.ier. or entity in I'm: Matter?
\ JVcs kl-No
NOTP: If you checked "Yes" in Item D.l proceed to fscsts D.l. and D.3. If you checked "No" to Item D.J., proceed to Part fc.
Unless sold pussuasit to a process of competitive bidding, or otherwise penaitied, no City
elected official o; employee shall have a financial interest in his or be; own name cr is the name of
any other person or entity in the pure-base of any property that (i) belongs, to the City, or (ii) ?s sold
fo: taxes or assessments, or (iii) is sola by virtue of legal process ;;t the suit of the City (collectively,
"City Property Sale"). Coutjwnsaiion for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of Usis Part D_- _ ._ _
Does the Matter involve o C«Ey Property Sale?
[JYes 5 JNo
If you checked "Yes* to Item D.l provide the names and business addresses of the City
of/Tctals or employees (saving such interest and identify the nature of such interest-
Name business Address Nature of Interest
4. The Disclosing Parly further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee:.
I-. CERTIFICATION KGUARDING SLAVl-KY liRA BUSINESS
Please check either l. or 2. below. 1)' the Diselosmg Party checks 2., the Disclosutg Pany ciu-st disclose below or in an aiicchracnt to this F.DS all information required by pamgruph 2. Failure to
PageS of IS
com ;•.!%• Wilh ii--;.--: d;-:.:!o?i!ie ;¦¦¦;[¦.;iremeiU:-' n»:l.y make .my comr-ei entered into v/hh the C:vv in connection wii.h 'vjaue; vouialile by ihr Cs!
i. The Disclosi".*? par!;/ verifier- ih:H '.he. Oisclosotv. P.iny ic.s sc-r'-.:if.r-U aiiv ;mu records of investments or profits lroin slavery tn slave aokK*:- tnsumncc policies during, die slavery era * including insurance policies issued to slaveholders that provided covers tic for damage to or injury or demh of their slaves), and the Disclosing Pmty has lound no such records.
_ i. 7'he- 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 lb at the following eoastit u'.es full disclosure of at! such records, includim-: the names of any and all slaves or .slaveholders described in those records
SECTION VI- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. if the Matter is out federally funded, proceed *o .Section Vii. for purposes of this Section VI. (ax credits allocated by the City and proceeds of debt obligations ofthe City are not federal funding.
A. CERTIFICATION REGARDING LOSKYSNG
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1905 who have made lohhying contacts on behalf of the Disclosing Party with respect to the Matter: (Addsheets if neecssairy);
?., The. Disclosing. Party has not spent and will not expend any federally appropriated funds fo pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law. a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federal?v funded g.ranior loan, entering into any cooperative tVjireemcnL or to extend, continue, renew, amend, or modify any federally funded contract., grant, loan, or cooperative agreement.
i';tv^ « of 1>
>. i ive (}::.; lusinf: Party v. :!i suhmii an u;^;;iii;d cvtiftcafiti:: a! \h-: end ofcrieh calendar ouane; ::\ v. iv.zh iitcre oceurs any event thai niaieri.illy nO'eeis ihe accuracy of l.bc sintemcms n;;d infoiiitatson set fori?; in paragraphs A,!, end A.2. above.
¦1. The Disclosing Party certifies lii.-it either (i) ii is not an organ txittiou described in section 50f(c)(-i)of the Intern;:! Revenue Code of VVM^ or (in i: is an organization described js section 30t(c)i4)of the internal Revenue Code of 1086 but has not engaged and will not engage tn "Lobbying Activities".
5. if the Disclosing Party is die Applicant, the Disclosing Party must obtain cei'tifica items equal in font! and substance to para&mphs A.I. through A.-1. above from all subcontractors before it awards any subcontract and the Disclosing Party must nmimain aii such subcontractors* c&ftificatiotis for the duration of the Matter and must make such ccrtifieaiKicis piorsipt'y available n> the City upon request.
ft. CERTIFICATION REGARDING EOUAL 1.-.MPLOYMfcNT OPPOKTUNSTY
if the Matter is federally funded, federal regulations require ihe. Applicant and ii It proposed subcontractors to submit the foll'pwrm? information with their bids tn in writing at the outset of negotiations.
ts the Discloss.-tg Party the Applicant''
_I) Yes []No - - -•"'
If "Yes.** answer the ibrec questions below;
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 Cf-"R Par. 60-2.)
(JYes [JNo
Have you filed with the Joint Reporting Committee, the.Director of Ihe Office vC federal Contract Compliance Programs, or ihe ttqual Employment Opportunity Commission all reports due under ibe applicable filing requiremecss?
[ ] Ycj. \ j No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause''
(I Yes [] No
if you checked '"No" to question >, or 2. nbovc. please provide an explanation:
SECTION Vil a C KN0WL EIX;MKNVS. CONTRACT INCORPORATION. COM SM ANt "PENALTIES. DISCLOSURE
The Disclosm;: Party understands and :i.>-:.'ees th:?;;
A. Ph.; ccr.ij'r-jiiosis, enclosures, and acknowledgments eomamcd in this !;DS will become part of any contract or nt'iKi1 agreement between the Applicant aj-d the Cily in connection with the Matter, whether procurement. City assistance, or other City action, and arc material inducements lo "he Cilv'x cxecuhon ni any contract or taking oilier action with tespeci to the Matter. The. Disclosing Party understands that it must comply with all statutes. ordinances, and icgulai'mtis on which 'his EDS is based.
ti The City's Ethics mid Campaign Financing Ordinances:. Chapters 2-156 and 2-164 of ihe Municipal Code, impose certain duties and obligations on pontons or entities seeking City con tracts, work, business, or transactions. The full text of these ordinances and a training program in available on l««e at www xitvo feb ii;a ao-omy'l Uhics. and may also be obtained fnuit the City's Board of Ethics. 740 N.
Sedgwick St., Suite 500. Chicago. iL OOdtO. CM 2) 744-%60. 7'hc Disdosmg thirty must comply fully with the applicable oidmanccs.
If the City determines that any information niovidcd in viiis EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is sitbrniiied may be .rescinded or be void or voidable, and the City may pursue any remedies under die contract or agrcewient (if cot rescinded or void), at law. or in equity, including terminating ti:e Disclosing. Party's participation in the Matter andv'or declining to allow the Disclosing Party to participate m other transactions with the City. Remedies ;»t law for a false stiitc-mem of material fact may include incarceration and an award lo the City of treble damage;:.
It is the City's policy to make this document available so the public on its Internet site and/or upon request. Some or alt of the infonnation provided on this EDS and any attachments, to this EDS may he made available to the public on the Internet, in response to a Freedom of Information Acs request, or otherwise, tty completing and signing this EDS. the Disclosing Party waives and releases any possible rights or claims which it may have against the City m coiKicctton- with the public release of Information"~ contained in this EDS and also authorizes the C'ny i<> verify the accuracy of any information .submitted
in ibis EDS.
E. The information provided in this EDS must lie- kept eiiitvii!. b» t?ie event of chatties. Ihe Disclosing
Party must supplement this EDS up to the time the City lakes action on the Matter. If the Mailer is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTjJ: With respect 10 M suets subject lo Article I of
Chapter 1-23 of the Municipal Code (imposing PER M ANENT INEl J.CtBlLlTV for certain specified
offenses), the information provided hcicin regarding eligibility mnst be kept eurreni for a lon;;er period.
ns required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents afid warrants that:
P;.;:.; 1! oi'
: ne t.Msc;osjf!!; j'.mv is not H.-\n,.- ->« .•. ....... ..
u-.pafrmcni oi Revenue, nor arc the Disclosing I'.ir'y or us Affiliated Hn:i:;cs 0-'h—r< ;,
t:i" °** o:|tc: dK"-!- 'JWC(! '0 «heCity.~TTii«'«ieludcs. but i:. not i'-niied -o'ai: ¦''^^i'^r'' sew'F-2 ,!"th''- Disck,?:'* Par» ls [fic Applicant, the Disclosing Parrv and i.s Affiib.ed F^iic-, Ww ^e. nor pcrrru, tber subcontractor to use, any facility listed by the U.S. f- J'.A. on the fed-rnl FwlfHc •'Sr!?VS M" S-''stcra ("GfLS") maintained by the U. S. General Service* Administration.
¦".3 If the Disclosing Party is the Applicant, the Disclosing Pam- will obtain f,'aIT. -nv
. ontraeto^suoeontractor, hired or to be hired in connection with the Matter certifications couai in
IT a"a SUhSWm:c U> in «¦ ™« «ot, without the prior writ,™ consent of dv
t .iy. use any sucn contractor/subcontractor that does not provide such certif.catir.m, or «b:.« .fcr"
',,SC!0SK!8 PaI1y ?,as IcaSon ,0 bcliCve «'« »« provided or cannot provide trmblul cenif.cauons.
NOTJi: tfthe Disclosing Party cannot certify as to any ofthe Firms in P.! F.2. m f 5 aM.w „ explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (I) warrants tlu,. he/she is authorised lo execute ifcu EDS anu Append,, A (if applicable) on behalf of the Disclosing Party, and (3) warwni* u,,. certnteatwns and statements contained in this EDS and Appendix A (ihmplkuhle) ore true Kecora"-
. ar.d complete, .wo i the date- iumisbed-to the C'ityr" "" — " ~ ~ "" ~ "
Soati !-"iirnits- I'nw Ir-nitt^^ypc^mc of Disclosing Party)
, (Jlt> here) ~~ ; ""'
_Jiife K Sues
(f Tin t or type n.outc o f person sign fog) TttKtep
(Print or type title of person signinij)
Signed and sworn to before me on (date) jMpJ /0. .< "
31 -£°ok , County, Illinois (stale).->
/ '/ i1 i A >rwai»^(^•-^2^-—.- _ _ _ No,.iry PubHc | C?FICfAlS£At
| MSUMDA LAWR3iC£
Coinmbision expires- « MtR&'y Pcaltc • Swu ol (i&ttis
——• ' $ My Cotamfssicn Eclrss Sea 5.2517
CITY UK CHK'AC.V: KCQNOMIC DISCI-OSCRK STA1 l-.MF.NT AXl) AFFIDAVIT A PPKNDl v a
KAMIUAI. RELATIONSHIPS WITH FA&CTF.D CITY OFllCiAl.S AND DF.PARTMKNT UK.ADS
This Apjtcndis is to be completed only by (a) the Applicant, -:nd (b) any lens! ei:li.ty which has :i direct ownership interest in the Applicant exceed i.r.« 13 percent. I' Is not tn be completed by any legal entity which haji only su Indirect ownership interest in (tie Applicant.
" 'sder Municipal Code SccDor --154-015. the Disch&iug Party must disclose wnctficr such Disclosing Party or any 'Applicable Parry'* or any Spouse or Domestic F'-uUvcr thereof currently etas a "fimilisl relationship" with .my elected city official cr department head. A ""fei'uili.'ij rcla:.;i!:i;-!-.;p'" exists if. as of the date this liDS is signed, the Disclosing Pony or any" Applicable Party" or any Spouse or Domestic Parmer ihcieof is related to the mayor, any atdennai:, the city cleri;. the city treasurer s any ofthe following,, whether by blood or adoption.: parent, child, brother or sister, aunt or uncle, tttccc vtr nephew, grandparent,, grandchild, father-in-law. inotlrcs-m-iaw son-in-law. "Applicable Party' means (1) all executive officers of the Dsschwms Party listed in Section IIS. I .a., if the Disclosing Party is a corporolion: all partners ofthe Disclosing Party, if ilw Disclosing Party is a general partnership; ali general partners and limited partners ofthe Disclosing E'.iny. if ihe Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if tlte Disclosing Party is a limited liability company. (2) all principal' officer:! of the Disclosing. Patty, and (3) any person Raving more than a 7.5 percent ownership interest in die Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief finnnctal officer, treasurer or sccreiaiy ofa Icjyd entity or any person exercising, similar authority.
Doss the Disclosing Party or any * Applicable Party" or any Spouse cr Domestic Partner thereof currently have a "familial relationship" with an elected city otFreird or dcparti'neni head?
1 I Yes . IXJ No.
If yes, please identify belovu (.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 lamilud relationship.
citymj-- chic act;
KCONOivuC DISCLOSURE STAT"F.Mw> F AND A)'K'D;vV:T
AF'.'LX?}iV
BRUMS': COiifc. ACO^'CaV; /PkQBLF.M LANDLORD CKHTSFlCAT!f>!"'.
Tfeb App-"?dh h- in compkrkt' oary hy ^ ihe Applicant* and f» any ksai cjrrify wbteb h-.i<, :> di-rccf ownership biu-rcs? itr Joe Applicant cxtattding 7Ji percent i-m "Owner***. U is not «o be cumnkicd Isy any legal estity vri-rcft ass rv.-.ly i:-u irti'irccl ov.ViSn.'dip jct6r«5* in me Applicant.
i. i'urstan: io iviibHCiptu Code ciecuon 2-i54««J0. rc the Applicant or any O.vcer identifo-d .ts :•• bi.'tJtlvt" rode seyf'law or pro&fcm landlord pursuant fo Section 2-92-416 ol die Mtuvripal
Code?
i JYes fXjNo
~- is'^tc Applicant js a Icija-I entity ptiblicsy traded ojj any cxdrjtnce. »s any officer or tJireu/o" of the Applicant identified or. a building code scofflaw or problem landlord pursuant «> Seetion 10 of the Nftrnk;|*ti Code?
[ I Yew I JNo fXi Not Applicable
J. if yes. .0 ii) or Ci)a&o\c. piearx? identify below the name ofthe pcrso« or legal etmry
idcttltilal a? 0 butldcng code scofvlav. or problem tandrord and the address ofthe building ->r buildings lo v.'ftich the pertinent code violations sppk.
HLLfNC ODT THiS APPENDIX tUrONSllTUTSS ACKWWLEDGftSKJVf ANT) *CR£F.?C£NT THAT APPENDIX S ift€ORPO*lA?ED BY NEFKRBNCE INTO, AND MA0E A PART OF. T\l£ ASSOCIATES) EDS. AND THAT THK REPRRSEjXTATIONS MADE !N THI.S APFHNDiX B AWE. SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PER.ITJRV ON PACK 52 OFTHE ASSOCIATED EDS.
CITY Of CHICaCO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -CENERAE INFORMATION
A. Legal name of the Disclosing Party submitting this I:DS. Include uVb/a/ if applicable: CA Venning 1 l£S. U C"
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: 1. f ] the Applicant OR
?,. ][>d a legal entity holding a direct or indirect interest in the Applicant. Stale the legal name ofthe
Applicant in which the Disclosing Party holds an interest: 1136 Soudi Wabash.;.!.(.'
OR
3. [ ] ii lcgas entity wilh a right of control (see Section W.B.I.) State the legal iuwc ofthe entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: U>l N. Clari; St SwtcWin
CXiicago.lL^tjOl
C. Telephone: :>»2ft.»6.6';:>7 Fax: Entail: jsOaA^ma
I.). Name of contact person: Koiunito K. Awsia
E, Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter'") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development for 11.56 - 40 S Wabash/^ (•:. Rwcli Rd.
G, Which City agency ordcpnrtxncni is requesting this EDS? PPD
If (he Matter is a contract being haiidJcu" by the City's Department oHVocufCincitt Services, please complete the following:
SpectilciHioii U and Contract # _
Page I of 13
SKCTION 1! -- DlSCl.OSUKK OF OW.VIf WSHIP INTF.I'iK.S IS
A. NATURu OF 'J HK DISCLOSING PARTY
1 indicate the ;i:;ma' eN f^-^On |X.! i.irm-d iiab-'uty comp:.uy
[ 1 Publicly icfttnicrcd business coipuration j ; Limited; liabiliiv partnership
J ] j-Vivateiy f-.uid biisines? eorporauon f ] Joint vt:n;;:r:;
{ } Sole prcprieto.'stsip ( ] Nol-for-profs? corporation
( j r.etieml partnership (I-s the not-for-profit corporation also a 501?
[ } Limited p.nrincrj.ifijp [ ; vos ^ 5 v0
(j lra;ri " f j Other (pfen.«: specify)
2. For legal entities, thestale (or foreign country) of mcorporaiiuu or cr^;»r. bait ton, if applicable:
j. For leyal entities not organised an the State of iilinois: Has the organization registered to do business in the Siato of Illinois as a foreii'.ii siiiitv'.'
f 1 >'cs _ |xj No j } \V.
U. IF TllH DISCLOSING PARTY IS A LKGAL liNTlTY:
I. List below (he full names n»d lilies of all executive ofitccrst and «f f directors ofthe entilv. NOTE: For not-for-profit corporations, ahio list below all members, if any, which ;ire legal entitle;:, if there ore no such members, write "itu rciciabcrs." For trusts, estates or other similar entities, list be?ow the legal titlcholdcrfs).
IT the entity js 3 general pamjterentp, limited partnership, limited liability company, limited liability partnership or joint venture, list below the mitnc and title of oshycucia? paiuun. intioaginrj member, manager or any other person or entity that controls the day-to-day manKgciaeat ofthe Disclosing Party. NOTE: Bach legal entity listed below must submit an EDS 00 in; own-behalf.
Name
CA Kfaiagr, LLC Manager
2. Please provide ihe following infonnation concerning each person or entity having a direct or indirect beneficial interest (including otwierrfiip) i-. execs."; of 1.5% ofthe Disclosing Party. Sfcisjiples of such an interest include shares in :i corporation, partnership interest in ;i partnership Of joint venture.
Prijic 1 of J 3
:."/¦.'¦ : i ;;k:i x.t .;:.:: i::ri:: ::; ;i Imiutid i.aliiiity Campari) . «).' :ntCIC5! d .1 OCIrcirCiart t» 1* a ;;'U.Ni.
¦.:M:lii- Or .:ihe. simiiat v.::i!:: y. W !:i.'>^:. ~.VMc "NaiH:." iNOTL: F'ur^ujni lo SCC1 ri.:2- i .V -(/'.SO i.'l Mumcipnl Code of Chicago ("'viuiuopal Code"), ihe Ciiy m-.iy rwpdrt: :my m:i:;i :iddi:i>;0!!l illi V applicant v/:;;cfi IS IVa.ji.'-l'i.lb''•' intended lo :iesi:e.V-:: fllii f! if.C «i';.-:<.i J"C:.
N:tmv i-l-.-Xini:-:* \i I <'.:".;:;••' ''irtvOi:!::;.;-: IvriCfCs! the
Disclosing Party
.Sow I-»m!vTa«». flail: Si . Ssiifr JS\m, OncaRo.!i. AlttlM ICR-;
JUic h. Souil 20t2K»iitlv 'I'iifcl. Uil (.'...'.it. Si .S-;:i:.c^!;i. l.ivir^o. ILMV/ii 5i:'va
SECTION Hi -- BUSINESS RELATIONSHIPS WITH CITY £LLC."T'i"> OFFICIALS
lius the Disclosing Parly had a " business ictariotiyhip," as defined, in ChisjHcr 2-156 ofihc Municipal Code, wiih any City elected official in the 12 months before the date tins LOS i.< signed?
(JYes WNo
If yes. please identify below tie name(s) o;\su;;h City elected ofi**chl(s) and ttcscriiu: such rclniion:;hip{sf:
SECTION IV - UlSCLOSCKIi OT SUBCONTRACTORS AND O THER RETAINED PAKT'&S
The Disclosing Party must disclose ihe name ami business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom tht; Disclosiu.!; Party h:is retained ni expects lo retain in connection with ihe Matser. as well as the nature ofthe. relationship, sod the mud amount ofthe fees paid or estimated to be paid. Ttie Oisclosiiif', Parry is nnl required to disclose employees who arc paid solely through the Disclosing Party's regular payroll.
"Lobbyist** means any person or entity who undertones £t> influence any legislative or administrative action on behalf of any person or entity other than: (i) a not-for-profit entity, on nn unpaid basis, m (2) himself. "Lobbyist" afso means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required wider this Sect ion, ih« Disclosing Parly mus>" cither ask the City whether disclosure is required or make the disclosure.
.".'aiu*: •'':»t»i.I;<;»U- wbch.T Usi:vt;ss ft'-S;ii«w$hip ' V:.;:l:'m::i:;;.; Party Fees ^isdiet'.te whcthrr
;cta:!'i-.:d Oi :i::lit':j>::!t.:;! Address (Si:bvo.'!l.*;:;.-ti:r. attorney, paid <:>r e-s"im:;.lcdl I
to be retained) lobbyist, etc.) **l>om»y tatc" or '"t.b.d." is
no- acceptable r;\:sui:vsy.
(Add sheets if necessary)
$i) Check hero if ihe Dtselosinj: Party has not retained, nor expects to retain, any such persons or entities. SEC HON V — C K i < TJ F i C A TIO N S
COURT-ORDER HO CHILD SUPPORT COMP1.1ANCK
Under Municipal Code Section 2-92-415. substantial owners, of business entities than cyjitrae: with the City must remain in compliance with their child support obligations throughout the contract's term.
Has sny person who directly or indirectly oxvns 10% oi more of the Oisclo-sbig Party bee?! declared in arrearage on :my child support obligations by any Illinois court of competent jurisdiction''
\ {-Yes — (xj No [-j.No-p*»son.-d»iec*ly-0»indirectiy-<>vvns 10% ormare of the
Disclosing Party.
If "Yes," has the person entered into a court-apf»roved tigresoicnf for payment of all support owed and is the person in compliance with that agreement?
I J Yea f ] No
FURTHER CKRTIFICAT10NS
I. Pursuant io Municipal Code Chapter 1-23. Article I ("Article J"K which the Applicant should consult for defined terms (eg., "doing business") and legal requirement), if the Disclosing Party submitting- this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of. or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article ! is a continuing requiretucot for doing business with the City. NOTK: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 ;md } below.
-. i -:-c .:>is%:losing ram .iriii-: 'the Disclosing F.iriv u a ict^ai cntriv. a?/ of(hose persons or entities :<:i:;:i!ifi:;.i.i in Section !! ii.i. ...i
nrc no; pr-j-scmiy dtrharrcd. si'soundo:!. proposed for debarment, declared mc-itdblc or vohintariiv excluded from :\-:,y tmnsacttoiis by any federal, sia.ic oi local unit o; government;
:i h::vc no'., wiihn: mc-y--<>r p«tri-id picoi'dmy. i';.; d:::o i.ii ' tYn.-i i-.DS, hc^ri convicted -)! a criniimd offence, adjudged guilty, or had a civil judgment rendered against them ::t connection with: obtaining, attempting to obtain, or performing a public (federal state or local) triinsucison or contract under a public transaction; :i viidatii.ni of fedeml or stale antitrust stisiiitc;:; frfiud; 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 govct'DUtettUil entity (federal, state or local) with commuting any of the offenses set forth iu clause B.2.b. of this Section V;
have not, within a five-year period preceding the dnlc oft his CDS, had one or more puldic transacttons (federal, state or local) terminated for cause or default: end
o. have not. within a five-year period preceding the date of this te'DS. been convicted, adjudged guilty, or found liable in a civii 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 oi local government.
3, The certifications in .subparts J, 4 and 5 concern:
? the Disclosing Party:
* any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all pensions or legal entities disclosed under Section IV. "Disclosure of Subcontractors and Other Retained Parties"):
any "Affiliated Hntity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Parly, is controlled by the Diode*.-rig Party, or i», with ihe Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking maoagciyetit or Ownership; identity of imciesris among family members, shared facilities aad equipment; commoji use of employees; or organization of » bvsiuess entity following tiie ineligibility of ti business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as *bc ineligible entity); wilh respect to Contractors, the term Affiliated l:iiii:y means a person or entity that directly or indirectly controls the Contractor, is controlled by it, of, with the Contractor, iy under common controt of another person or entity:
any responsible official ofthe Disclosing Party, any Contractor or any Affiliated F.ntiiy or any other official, agent or employee ofthe Disclosing Puny, any Contractor or any Affiliated 1-nliiy, acting pursuant to the direction or authorization, of a responsible official ofthe Disclosing Party, any Ctmtmcior o; .my Affiliated Entity (collectively "Avails").
Page 5 of ! .i
Neither Lb.-; Disc-ifiS-m:- i'r.rty. -;or a;:;y C>:i!i7.:c A iTt!::.icd hr.iiiy oJ either ;hc DtselosH-i; l':i-'.\ ••ii any Contractor noi any Agents have dii/niK.the fr-v yea;:.: befuic die date liiis HDS is signed. c-r. with .'e-'oex! u> o Cttv^tr:is;i».t:. A !"!':!!.-itt-.d I-.is!ii^. or an A ffi lilted I.-] nitty of a Cont.'yci.or .Junav ;:».: hvc yirar •, before die date of such Contractor's or Affiliated Utility's eon tract or engagement in connection with the
hribefl or rittcmpicd to bribe, or been convicted or adjudged guilty ofbiibcry or -.mem puns 10 bribe, a public officer or employee, ofthe City, ttic State of lijim'ii.s'. or any agency ofthe fed era] covcrntnent or of any siate or local K.ovevmncat in the United States of Amcricr »n that oflieerV or employee's official capac ity;
b. ayjeed or colluded with ot lis:-' btddc:?. or prospective bicdsrs. or beer, a pasty i<> ft«y .;.««ei;
agreement, or been convicted or adjudged guilty of agreement or coilusion among biddeis or prospective bidders, in restraint of freedom (>f co-ipciiinii) hy agreement to bid a fixed price or Otherwise; or
¦t. otsde an admission of such conduct described in a. or b. above that is
t.l. violated the provisions of Municipal Code Section 2-92-6)0 fl-iving Wage Ordinance).
A. Neither the Disclosing Party. Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state fit local government as s result of engaging in or being convicted of (I) h id-rigging in violation of 720 ILCS 5r*33ts-3: (2) bid-rotating in violation of 720 ILCS 5G3K-4: or (3) airy suutmr offense of any state or ofthe On Red Stales of America that contains ihe same elements as the offense of bid-rigginy or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of she following Us$s maintained by the Office of Foreign Assets Control ofthe U.S. Department ofthe Treasury or the Bureau of Industry and Seemity of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons last; the Unverified List, the Untity List ond the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (inspector Genera!) aod2-l56 (Governmental F.thics} ofthe Municipal Code.
;. If the Disclosing Party is unable to certify em :-,ny of ih* above statements in this Part 3 (Further Certifications), the Disclosing Party must explain below:
Pa&c 6of 13
It'tin; iviivix "NA." the word "None." or no ri:spon»; appears ov. th- lino-, .ibovu. I; will he ;-<>i>c'iii'.,:v«.'ly ;>rty:uini:ii i'n1 the Disc-losing Party certified m th? above sinicmenii.
•S. 't t. the hcyt ofthe Disclosing Party's knowledge atkr reasonable inquiry, the following u a complete iist of ui! current employees of the Disclosing Party who wert:, :i;iy time during the ! 2 month period j;t;;;::-dii!;: ihe execution date of this KDS. ;:••>'¦ employee, or elected or appointed official, ofthe City of Chicago (tf none, indicate with "N>A" or "none").
9. I :j «he best of the Disclosing 'Part> *>• knou ledge a i'ter fuasimahlc impairy. <«;« following t* a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-miit»ih period preceding the execution date of this EDS. to an employee, or elected or appointed offtctal. ofthe City of Chicago. Far purposes cf this statement, it "gift"" does nos include: (i) anything msde generally available to City employee:; or io the general public, or (it) food or drink provided m the course of official City business nnd having a rciail value of less than $20 per recipient (if none, indicate with '"NVA" or "none*"). As to any gift lisr.cd below, plcuse also list the name of the City recipient.
None
C CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
I. The Disclosing Party certifies th^t the DsNtdosing Party (clurck one}
L J is DO is not
.1 "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.
1. If the Disclosing Party IS a financial institutioH. then ihe Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge thai oone ofour affiliaics is. and none of them will become, a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. Wc understand that becoming a predatory tender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."
If the Dtv:;li.is::u: Party is enable to make this pledge because if or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pjiges if necessary):
Page 7 of 13
if 'the letter "NA. conclusively ptur.i
" the word "None." or r.o itspotiie ap-pc-ars on the lines abo ve. :i will be :::ied lhai t'ne i ji.scUs.-jiiiji I'ariv n;i~it;t' H> the at-ovi; '.-taieinenSi;.
?), CURTIFiCA'HON Rl:XJ AfUMNG i-NTKRL-iKT iN; CITY IJUSiNi-.SS
Any words or terms, that are defused in Chapter 2-150 of the Municipal Code have the same-meaning,? when used in this f':«:t 0.
in accordance wilh Section 2-l>fs-l 10 of ihe Municipal (!ode: Ones any official or employee ;-l the Cily 5:av« a financial inti-icst in liis ttr bi t v--.v:i nam-.: s>r in the nanus of :::iy ulncr pcnjOti «:r entity in ihe Matter/
[ J Yes k! No
N'OTG: If you checked "Yes" to Item D.i proceed to Items I).2. and D.3. If you checked "No" to beta D.L. proceed to Part t-.
Unbars tosri pursuant io a process of competitive bidding, or otherwise permitted, no City
ejected ofrlcisi 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 tiny property that (?) belongs to the City, or (iii is sold
for taxes or assessments, or (iii) is sold by virtue of legal process a! the satt ofthe City {collectively.
"City Property .Sale"). Compensation for prop.cn > taken pursuant to die City*s'ei«ii»cni domain power
.doeSJiot.eoii.^ttiule.:i-nsuujeia.lrulcre.s:t-u/-(lhiM.l]:<; meaning of Uiis .Pius TJ - -
Does the Msner involve a City Property Sale?
3. • tf you checked "Yes" to Item D.lprovide the n:tme$ and business addresses of the City
officitils or employees having such interest and identify the nature of such interest:
N'smc Business Addresj. Nature of Interest
4. The Disclosing Party fuitaer certifies that no prohidiied financial inlcscs! in the Matter will be acquired by any City official or employee.
6. CERTIFICATION RJECAKDI'NO SLAVi-KY £1
Please cbccV cither 1. or 2, below. If the Disclosing Party cheeks 2., the Disclosing Party most disclose below or in an attachment to this S:DS all information required by paragraph 2. Failure to
Page c! of i?
compiy v.ilfr diM-Joy;,-? rcq'.liromenK i!j;.y make any ronifsci e::ii:r-.rd nth;: wilh -he City in
conneetioi; -.vj:!; the Mauci voidable hy ihe City.
>• !. Tin: Disclosing Party verifies thy; the Disclosing Paity has searched any and all records of the Disclosing Party and a«v and al! predecessor entities rcgardme, records of investments or profit.?, truro stavecy or slaveholder insurance oolitic* durin« the slave ty ctVt (including insurance policies issued to slaveholder;: that provided coverage fo; damage lo or injury or death of their slaves), and the Disclosing Pany has JVnad no such records,
-. lite Disclosing Patty verifies thai, as a result of conducting th<; search in step ! above, the Dteclftsiog t'nny his found :cuords of investments or profits, from slavery orslavcholdc: insurance policies. The Disclosing Party verit ies that the following, constitutes lull disclosure of all such records, including the names of any and :;S1 slaves or slaveholders described in those records:
SECTION Vi - CERTIFICATIONS t'OR FEDKKAUY '.'UNDliD MATTRRS
NOTE: If the Matter Is- federally funded, complete this Section VI. If the: Matter Ls not federally funded, pioeced to Section VII. For purposes' of this Section Vl, ta.\ credits allocated by the City and proceeds of debt obliy^iiiim; of ihe City are not federal funding.
A. CF!RTi}•"ICAT30N RliCARDf.VO IOBWY/KG
I. Lis- below the names of all persona or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Pany with icspect to the Matter: (Add rdieets if necessary):
(If no explanation appears or begins on the lines above, or if the- letters "N A" or if the word "None" appear, it will he conclusively presumed (hut the Disclosing Party mean.': dint NO persons or entities registered under the Lobbying Disclosure Ac! of 19*95 have made lobbying contacts on behalf of the Disclosing Pany with respect to the Matter.)
2. The Disclosiiii? Party has not spent and will tun expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee ofany agency, as defined by applicable federal law. a member ofCon'gress, na officer or employee of Congress, or an employee of a member of Conures.;. in connection with the award of any federally funded contract, making any federally funded grant or loan, cnlcrinp. into any cooperative agreement or so extend, continue, renew, amend, or modify any federally funded contract, gram. loan. o». cooperative agreement.
Pufji: 9 Ot." 13-
v. The i>t:.;:lo>inr; Party wii; submit an. updated certification as the end nreach calendar cuarter in \vhich there occurs any event lira; maiitriaiiy affects tar: accuracy ol" the statements and information set forth in paragraphs A i. and A.2. above.
•'». The Disclosing Party ccttifics that enbcT: (i) it is not an organization described in scc:ior»
:>G1 i~e)(-i) Ol' the liitCMia'i Revenue Code of or (ii) ii. is an organization dcscrilicd in sceiinn
501(c)(4) of the I menial Revenue Code of 1 l)S6 bin has oo) engaged and will not engage in "Lobbying Activities".
5. U"the Disclosing Pany is the Applicant, the Disclosing; Party-must obtain certifications equal in ton:? and subitniiee to paragraph;: A. I. ihsi:i:!?.di A.d. ahuve IVo.-:s all seil'icoiiirciciots before iJ swards any subcontract and the LHsciosing, Pany must tn sinla in all such subcontractors' certifications fo: the duration of the Matter and rausl malic such ccrtifica-ions promptiy available lo the City upon request.
B. CERTIFICATION REGARDING EQUAL b:MPLOYMi.i,NT OPPORTUNITY
If the Matter is- federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the folsov/intj information v/ith their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
fT^cs (TNo "
I f "yes," answer the three quetsiiotis below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 'I I CFR Part 60-2.)
(j Yes {J No
Have you filed with the Joint Reposing Committee, the Director ofthe Office of Federal Contract Compliance Programs, or the liquid limpioyment Opportunity Commission all reports due under the applicable filing requirements?
{ 1 Yes ' f J No
X llavc you participated in any previous contracts or "ubeoriltac's subject to the equal opportunity clause'.'
{ | Yes I ) No
if yoa checltcd "No" to question I. or 2. above, please provide an explanation:
Page. I Oof 1.5
SKCTSON 'v ii ~ AC"K:NOWLiiDC;VJ«?.>'I'S, CO.VHi.ACT kN'COKPOKA'HOiV COMPI-fANCE, PENALTIES. DiSCLOS'UKE
Tin; Disclosing Pany iinder^iands anci agrees thai:
A. The certifications, disciosutes, aad aekitowkdnmetiis continued tn :hts liDS will bccoaie purl ul tuiy cool roc*, or other agreement between the Applicant and the City »n connection with the. Matter, whether procurement. Cnv assistance, or other City action, and are material inducements to Ihe City's cxucuttfu'i of any contract or uiking other action with respect to the Matter. The l>i.*::!o$ms> Pany understands that n must comoiv with nil .-JatnScs. ordinances, and regulations on which this Lu>:S is b:»scd.
fl. The Cily'--. Governmental Ethics and Campaign Mnitnein-i Oi'di.-.vanee.c, f"hap'era 2-i56 .ir;d 2-16* of the /vtusiicip'd CshI*-. impose certain duties ;i*sd obligations on persons <>: entitle* seeking City contracts, work, business, or lrans~iclio*is. The full ic.xt of these, ordinances and a training program is available on line at wjyw.eityqfchicflgo.org/Ethics . and may also be obtained from the City's Board of Ethics. 740 N.
Sedgwick Si Suite 500, Chicago, !'-. 60610. {31 j) 744-96G0. The Discl'isi'isy 5'ariy ntnsrt comply fully with the applicable oidimraces.
If the. City determines thai any information povkk-d rn this EDS is false, incomplete or inaccurate, any eontroe' or other agreement in. connection with which it is submitted may be rescinded or be void or voidable, and the City way pursue any remedies under the contract or agreement (if not rescinded or void), at tow, or in equity, including. Ccnoiuuiioii'. ihe Disclosing Party's participation in the Mutter nrubnr declining lo allow the Disclosing Party to participate in otbes traosaettoiw with the City. Remedies at law for a false statement of material fact may include incarceration and no aw.-.rd to the City of treble damages.
it is the City's policy to make ibis document available to the public oo its Internet site and/or upon request Some or all of the information provided on this EDS and any attachments to this F-DS may he made available to the public on the Internet, in response u» a Freedom of information Act request, oi otherwise. By comptetinjj and signing this EDS. the Disclosing Party waives and releases any possible rights or claims which it may have Kjyiinst ihe Cily in connection with the public release-of information contained in this EDS and also authoriy.es the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kepi current, in the event of changes, the Disclosing; Pany must supplement ibis ?*DS up to she time the City i.ikc: action on the Matter. If the Matter is ;i contract being handled by the City's Department of Procurement Services, the Disclosing Party roust update this EDS as the coiUuicl requires. NOTE: With respect to Matters subject to Article I of Obapici 1.-2.3 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter l-2.i and Section 2-154-020 oft.be Municipal Code.
The Diselosinf; Party represents and warrants that:
Page i I of 13
}¦.! . the S / ! Ij 1.;. ;*:sr:V .-;i.!i OeJliKjlieiil in 'he p.iyiljt':! :.)' n:iV i.c:X :id.^m':i,;ai::i:(i yv !.;;;e " i i niois
Department ul Revenue, nor are ibe Disdosin.Ej Pany or it;: A ffiliate d Entities dclinc-iicni in paying any ("ne. fee. tax or other charge owed to the City. This includes, but i.<. no! limned to. ali water charger*, .sewer ehat'jje:;. license fees, parking tickets, property laaes or sales taxes.
F.2 If the Disclosing Party i» sbe Applicant., the Disclosing Party and iu; A filiated Entities will sot ¦-¦sc. nor rscrndi their subcontractors to we. a ay facility listed by she U.S'. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disd-osbg Party will obtain from any ei.:ol.rocto-s.'subeutnmeiors hired or to be hired ia connection with ilse flatter certifications i:
NOTE: If the Disclosing Party enrmoi certify as lo any of lae tlenis in F.l F.2. ur F.3. above, an c>.pl;in;ilory statement most be attached io this i:?>S.
CF.RTIFiCATiON
Li rider penalty of perjury, the person rigaing below: (i} warrants that he/she is autiiori/cd to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing. Party, and (2) warrants that alt certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
i'A Vcf4«jrcsi Holdings. LUC (Print or type name of Disclosing. Pany)
(Sign here)
'lianas tvl. Sec:: (Print or type lsame of person signing)
Maaapi:; Mctabar pf Manager
(Print or type title of person signing)
Signed and tfwora to before me on (dniej jy$Jr. > * t >gj j
at Oao* _ County. I^rtflls (stale).
i / t v.f /! . * .J^-""""
^Ji.'hi/l . r--- ' — r-~ — Notary Public. ,; — -^iVie.
tf ^(0fFJCtttSEAl"' "•^^
Commission expires: fl ^UQQA LAVUH^g P
Par*: I?.of n
- - --•-'-c.t.-v:^-:.,,
Cil'Y Ui-' ("!!!(AGO h*.Ct)N();V'K.: DI-SCi.OSljRE S'j 'A TigM ENT AND AFFIDAVIT APPENDIX A
F-YMIUAL ur:AT!0-vSiiiPS WITH 'liLV.ClT.ii CuY OFEICIAJLS AND DEPARTMENT HEADS
This Appendix is to he completed only by (a) Hie Applicant, and (b) any Je^a! entity which has a direct ownership in torus' in the Applicant eveeeding 7.5 percent, i.l is ant fo be completed bv any legal entity ••vhich has only an indirect oivncrs-hip interest iii the; Applicant.
IJndej Municipal Code Section 2-154-015,1 list Disclosing Pajty aiusl disclose ivhe-he/.^fcb Disclosing Party sr any"Applical.de Party" or any Spouse or Domestic Partner Unscof currently bus a *tarmfuil relationship" with :;:y elected city official or dispsirt/Reai head. A "lamilud rejaiionshir!*' exists iii as of i.he dale this EOS is signed, ine Disclosing Party or any "Applicable Piuty"or any Spouse or Domestic Partner thereof is related to the mayor, any aldermau. the city clerk, ths city m-isuror or any city department head as spouse or domestic parmer or as any of the following, whether by blood or adoption: parent, child, brother ors&cr. aunt or uncle, •titscc nr ncohe'.v. grandparent, grandchild, f«ihcr-in-faw\ rno;her-tn-biw. son-in-law, daughter-in-law, stepfather crstepiKoihsr. stepson or sicpdauiditc;, stepbrother or stepsister as half-brother or half-sister.
"Applicable tVirty" means (I) all executive ofTtccrs of the Disclosing Party listed in Section IIJJ. 1 .a., if the Disclosing Party is corporation; all partners of the Disclosing Party, if lite Disclosing Party is a gcttcral (lariiscrship; all gistcntl partners nyd limited partners of the Disclosing Party, if ihe Disclosing Party is a limited partnership; all managcre, ntatiugins incmbcirs and mcmbets of the Disclosing Party, if the Disclosing. Party is a hmrlcd l&bitity company; (2) ail principal ofTiecis nft.he Otsclosiiisj Party; and (3 j any person having «tore than, a 7.5 percent owiserslup interest in the Disclosing P:i«ty. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a iet»al entity or any person e,\erctsin;> similar authority.
I )mss the Disclosing Party or any ''Applicable Party" or any Spouse or Domestic Partner Uieicof currently have a "familial relationship'" with an elected city olficial or department head?
f 1 Yes (X< No
If yes, pk:sse identify below (I) the naiise ;uvd title of such person. ("?.) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city u facial or department head to whom such person has a familial relationship, and <4) the precise tmtureof such familial rclttliaaship.
ECONOMIC• DISCLOSURE STATEMENTAND AFPlDAVf!
finp?,DIKG CODE SCOFF; ,AVv!VRi>Yi,i.:'M LAi^LORO CFUTK iCA'TlO':
Phis Ap£ic::dii b fo be cnntpfrted ooi;, by (;;:) iJ?>: AptrKcsnt and (b) iir;y it?«al v.;ut} .v !»»srh has a direct «*j3«*sfes.p interest in the Applicant exreed-titg 7J5 percent: (an "Ownrr**). it is tioi to ba completed by -any ?e;>u! entity *vhic?i has c.nty icdireci ovraciShlp loranst is i'-'c Atiplicit!*.
'. Pursuant :.0 Municipal Code Section 2-154-010, is the Applicant or any Owner identified jt. a ;:uilc:;i£ t;«de scui'iW ar probeem laitdvord pursued to Section 2-?2-4io oI'un- Mucicipai Code?
I I Yes iX]^
2. Ifthe Applicant is *Icyii cmity publkly traded on auy exchange, is any officer or director <••-tltc Applieanl id^niilicd as :: bunding. sciifllau or problem btn^iiird pursuant to Section 2-92-150 of the Municipal Code?
f']Ycs [ }No DC]Not Applicable
3. if yes to(2) Or iZ) above, please identify below the name ol the person or tygai c*U'«y
identified as a busfdwg code scofllaw or problem landlord: owl die address ofthe building or build tugs to which five pertinent code violations- apply.
FILLING OUT THIS APPENDIX & CONSTITUTES ACKNOWLEDGMENT AND AttREEirtENT THAT THIS AS?PfcN»IX 3 IS INCORPORATED BV KEF£RE?V*CF. INTO, AND MADE A PART OF. THS ASSOCIATED EDS, AND THAT TI1E RKPRSS-KNTATION-S MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY OiS FACE 12 OFTHE ASSOCIATED EDS.
CITY OF CHICAGO KCONOM IC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name ofthe Disclosing Paily submitting this EDS. Include d/b/a/ t)' applicable: Keith Giles Revocable Trust dated September 16. 2008
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party subi'niliiiig this EDS is:
f ] the Applicant
OR
[X\ a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 2£> Bast IWeveltl.l,C&QVKG 1 Wabush
OK jv.u.c
3. [ ] a legal entity with a right of control (see Section U.B.I.) Stale the legal nasne ofthe entity in
which the Disclosing Party holds a right of control:
1$. Business address of the Disclosing Party: _ U56 RidgeRoswl _
Tlj^idTafi. IE 68035
Telephone: 312-*3fr-fr937 Fax: Email: roiafldovftacwtug.igur.ci>™
Name of contact person: y^11*0 R ^*-'osia
K. Federal Employer Identification No. (if you have one):
F. Brtcl" description of contract, transaction or other undertaking (referred lo below as the "Maltcr") to which this F.DS pertains. (Include project number and location of property, if applicable):
Planned I tevctocmcnt for 1136 - 40 S. \Vr:uS:i:i!'/26 P. Roosevelt ftcrnd
0. Which City agency or department is requesting this F.DS? ,DPD
If the Matter is 0 contract being handled by the City's Department of Procurement Services, please complete the following:
Specification and Contract # _
Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PART Y
1. Indie-ale ihe nature of the Disclosing
| | Person
( | Publicly registered business corporation
j ] Privately held business corporation
} j Sole proprietorship
{ ] General partnership
f ] Limited partnership
f.Vj Trust
Parts-:
| ] Limited liability company [ I Limited liability partnership | ] Joint venture } J Noi-for-profii corporation
(Is the not-for-profit, corporation also a 501(c)(3))?
f 1 Yes f ) No
[ ] Other (pteasc specify)
2. For legal entities, the stoic for foreign country) of incorporation or organization, if applicable:
lUiaoii
3. For legal entities not organized in the Suae, of Illinois: Has the organization registered to do business in the State of Illinois ns a foreign entity?
lives
B. iF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below the full names and titles of till executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, ifany, which arc legal, entities. If there arc no such members, write "no members." For trusts, estates or other simitar entities, list below the legal Litleholdcrfs).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below most submit an EDS on its own behalf.
Name Title
Keith titles YnSIee
2. Please provide the following itiloitiiatioti concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. F.xarnplcs of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13
intetcsi i>l ;'i iiscn;bi.'! or manager mi :! limited !i;ibiiity company, o: interest of a bcnefiesary ol a trust, csialc or other similar entity. I f none, stale "None." NOTE: Pursuant to Section 2-1 5-V-030 ofthe Municipal Code ot"Chicago ("Municipal Code"), the Cily may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest, in the
Disclosing Parly
Ke-.ih <;;;»-.- _i-|5<, Kidtc Kfiid. I lic.hlan.-l Park. II, 6007.5 !«0%
SECTION 111 - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal Code, wiih any City elected official in the 12 months before the (late this EDS is signed?
\ 1 Yes UI No
If yes. please identify below the namc(s) of such City elected offkial(s) arid describe sucb telationship(s):
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist-, accountant, consultant and any otlicr person Of entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is noi required to disclose employees who arc paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself- "•Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
if the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must cither ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (, indicate whether Business Relationship 10 Disclosing Patty Fees (indicate whether
retained or anticipated Address (subcontractor, attorney. paid or estimated.) NOTE:
to be retained) lobbyist, etc.) '"hourly rate" or '"t.b.d." is
not an acceptable response.
(Add sheets if necessary)
K] Check here if the Disclosing Party has not retained, nor expect to retain, any such persons 01 entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-'.>2-4 15, substantia! owners of business entities that contract wilh lite Cily must remain in compliance with (heir child support obligations throughout the contract's term.
Has any person who directly or indirect ly owns lf>% or more of the Disclosing Parly been declared in arrearage on any child support-obligations--by-any -.Illinois coui'tof compeicnt jurisdiction?
| ] Yes IxJ No | j No person dircctiy or indirectly owns 10% or more of the
Disclosing Partv.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
{JYes { I No
FURTHER CERTIFICATIONS
I. Pursuant to Municipal Code Chapter 1 -23. Article I ("Article I,:)(\v!itob (he Applicant should consult for defined terms (e.g., '"doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is do teg business with the City, then the Disclosing Party certifies as follows: (i) nciihcr the Applicant nor any controlling parson is currently indicted orcharged with, or has admiticd guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, thefi. fraud, forgery, .perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the Applicant understands: and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: if Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.
! he Disclosing Party and. il' llic Disclosing I'ai'ty is a legal entity. ;ill ouho.se persons orcntuics identified in Section II. fl. I. of this F.DS:
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal. State Or local unit of government;
have not. within a five-year period preceding the date of thts EDS. been convicted of a criminal offense, adjudged guilty, or had a csvil judgment rendered against them in connection wilh: obtaining, attempting lo obtain, or performing a public (federal, slalc or local) transaction or contract under a public transaction: a violation of federal or stale antitrust stniotcs; fraud; embezzlement: theft; forgery: bribery; falsification or destruction of records: making false statements; or receiving stolon property:
arc not prcscnily indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses, set forth in clause 13.2. b. of this Section V;
have not, within a five-year period preceding the date of this EDS. had one or more public transactions ( federal, state or local) terminated for cause or default; and
c. have not, w ithin a five-year period preceding the date of this EDS. been convicted, adjudged guilty, oi found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concent:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractor 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 Parry, 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 organisation Of 0 business entity following the ineligibility of a business entity to do business with federal or slate or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly Or indirectly controls the Contractor, is controlled by it, or, wilh the Contractor, is under common control of another person or entity;
- any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents'").
Page 5 of 13
Neither the Disclosing Pan v. nor anv Contractor, nor anv A I'filiaicd Fntitv of either rhe Dlsclosim; Pariv or any Contractor nor any Agent:; have. durine the five years before the date tit is F.DS is signed, or. with respect lo a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the jive years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
a. bribed or attempted to bribe, or hecn convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the Slate of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity:
h. 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 iu a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
_ 4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agenls 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 simitar offense of any state or of the United Stales of America thai contains the same clemcnr? as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated' Entity is listed on any ofthe following lists maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable, requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
i
If the Disclosing Ptfrty is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Pap.c 6 of 13
U the letters "NA." the word "None." ur no response appears on the lines above, it veil: be conclusively presumed that the Disclosing Party ectlifted to the above statements.
N. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the t 2-month period preceding the execution date of this P,DS. an employee, or elected or appointed official, ofthe Cilv of Chicago (if none, indicate with "N/A" or "none").
None
9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any lime during the 12-montlt period preceding the execution date of this CDS, to an employee, or elected or appointed official, ofthe City of Chicago, for purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided iu the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "NM" or "none"). As to any gift listed below, please also list the name of rhc City recipient.
None
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1, The Disclosing Party certifies that the Disclosing Party (check one)
| j is jXJ is not
u "financial institution" as defined in Section 2-32-45 5(b) ofthe Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. Wc further pledge that none ofour affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of ihe Municipal Code. Wc understand tbnt becoming a predatory lender or becoming an affiliate of a predatory lender may result in die loss ofthe privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-4 55(b) ofthe Municipal Code) is a predatory tender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary)1
Page 7 of !3
If the letters "NA." the word "None." or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified lo the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any wotds or terms that arc defined in Chapter 2-1 56 ofthe Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-1 5 0 ofthe Municipal Code: Does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
| ] Yes fc] No
NOTE: If you cheeked "Yes" to Item D.l proceed to Items D.2. and D.3. Ifyou checked "No" lo Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property thai (i) belongs to the City, or (ii) is so?d for taxes or assessments.; or (tii)-is sold by virtue of legal-procoss at the suit-of thc-City-{cx)l.lccdvcly-"Ctty Property Sale"). Compensation for property token pursuant lo the City's eminent domain power does not constitute a financial interest within the meaning of this Pail D.
Does the Matter involve a City Property Sale?
L 1 Yes 13 No
Ifyou checked "Yes" io hem D.l., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
•1. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither 1. or 2. below. If the Disclosing Parly checks 2 the Disclosing Party must disclose below ur in an attachment to this EDS all information required by paragraph 2. Failure to
Pane 8 of 13
corr.pl v wiili these disclosim; require-mems may make any conlracl entered i::U» with ihe City in connection wilh the Matter voidable by ihe Cily.
X |. The Disclosing Party verifies 'hat ihe Disclosing Party has searched any and all records ol" the Disclosing Pany and any and all predecessor entities regarding, records of in vestments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step I above, the
Disclosing Party has found'records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of ail such records, including (he names of any and all slaves or slaveholders described in those records:
SECTION VI — CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City arc not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of l°°5 who have made lobbying contacts on behal f of the Disclosing Party wilh respect to the Matter (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA* or if the word "None" appear, it will be conclusively presumed thai the Disclosing Party means that N'O persons or entities registered under ihe Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party lias not spent and will not expend any federally appropriated funds io 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 arty agency, as defined by applicable federal law. a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant. loan, or cooperative agreement.
Page 9 of 13
T he 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 forlh in paragraphs A.l. a.od A.? above.
The Disclosing I'aiiy certifies that cither: (i) it. is noL an 'organization "dcscribed'insection 501(c)(4) of the Internal Revenue Code of !9Sk; or (ii) it is an organisation described in .section 501(c)('l) ofthe Internal Revenue Code of J 986 but has not engaged and will not engage :ri "Lobbying Activities".
If the Disclosing Party is the Applicant, ihe Disclosing Pany must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from nil 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 codifications promptly available to the City upon request
ft. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant','
( ) Yes { 1 No
If "Yes," answer the three questions below:
Hove you developed and do you have on file affirmative action programs pursuant to applicable federal regulations'? (See 41 CFR Part 60»2.)
f I Yes () No
Have you filed wilh the .loint Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or ihe Equal Employment Opportunity Commission all reports dot under lite applicable filing requirements'?
[]Ycs riNo
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ I No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Pare 10 of 13
SECTION VII - ACKNOWLEDGMENTS. CONTRACT INCORPORATION, COMPLIANCE. PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees thai:
The certifications, disc'ostites, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection wilh die Multcr, whether procurement, Cily assistance, or olher Cily action, and arc material inducements to the Cily'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 FiDS is based.
The City's Governmental Ethics and Campaign financing Ordinances. Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons Or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.eityofchicnfto.org/Eihics , and may also he obtained from the City's Board of Ethics, 740 N.
Sedgwick St Suite 500, Chicago, IL 60610. '312) 744-9660. The Disclosing Parly must comply fully with the applicable ordinances.
If the 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 die Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law {'or a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Parly 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 infonnation submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement, this EDS up to the time the Cily lakes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Parly must update this EDS as the contract requires. NOTE: With respect lo Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain Specified offenses), the information provided herein regarding eligibility must he kept current for a longer period, as required hy Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that;
Page 1 ! Of 13
I; !. The D;3elos»«ifi I'Jiny is noi dciine/jcnl :a the pajWBftt ofwy .-tihnieMtosi by tic Illinois 5>«>tsft»ia« of Revenue, nor an: Use Di:v;!L>i.i;!:- Parr.' or its Afft&ncii llslhsci dcikieJcrit i->ri<« o-a-cc ;o t>.< City. 11:is iochiJrs. tea tVeot lisnit'ed t«». aii wu-rei charges. :;F-2 If die l)iicto::>;r;j: Pany U 1*ns Appticani, the DiMclustn?. Putty and is Affiliated Entitle:: will not use. oor permit their schcnst^tcus-i: to use. auy facitfrv fisted by die GJS. EJF.A. osr Be feccm.1 F.xchiP.3 if tbe Discing**! P«ry is tr-. ApplicssZ. tic Dtfclesiag ?any *riil oSstais fwta acy t>.)iUi-jeloiSi'Sut>ei.»r.;i'.ie!.r!iT; H:wL :r: Sn be hirec i:i ctra»i'e«in.T with ihe N'auer ccclilkiiliatis. cquaS in timr. anu substiioec vo Ibosc in FJ. sad F.2. above iii:d wftl r»o% wijaont the phot written consent off.be City, uic a.uy .TCC't caHTr»CTOWu!>c:?r.ixaietur ihai ifiiei no* provide sacf> Cfftffisstioiis o: Chut dsc Disclosing Party hss fiasco b> beKevc has rate, provide*! or- cannot prcvlde-ewtfefui certifications.
NOTE: If the DiMloiiag'Party tifJirai ecriify i; to -any ol'tbe tlcaiS F.2.or 3'.3. above, art
explanatory stat.e?iwrrt tacsa &s-attacked ro Shu £3$.
CERTIFICATION
Keith OSlss
(1'riflt
(Print or type ddc ofprfSQi) Sȣ.isliig)
iiiuisr pcttaityofperjory. the pt&oo signing:bdouR (t}w&miU3 ihaxfar/Ebe is refhorixed to execute this VDS and Appendix A CU V OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
Familial relationships with elected city officials and department heads
This Appendix is tn he completed only by (a) the Applicant, and (h) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not ttt he completed by any legal enrity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently lias a "familial relationship" with any elected city official or department head. A "familial relationship" exists tf, ns ofthe date this HDS is signed, the Disclosing Pany 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 cily department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandpareni, grandchild, fathcr-in-lavf. molhcr-trv-law, son-in-law. daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or ha.l f-brothcr or ha I f-sister.
'•Applicable Party" means (I) all executive officers of the Disclosing Party listed in Section il.B. 1 .a., if the Disclosing Parly is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; ali general partners and limited partners ofthe Disclosing Party, ifl.be Disclosing Party is a limited partnership: all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner dtercof euiYcnt?y have a "familial relationship" with an elected city official or department head?
I ] Yes tX) No
If yes, please identify below (1) the name and title ofsuch person, (2) the name ofthe legal entity to which such person i$ connected: {3) the name and title of the elected city official or deportment head to whom such person has a familial relationship, and (4) the precise nature of Mich familial relationship.
Page 13 Of 13
CITY OK CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX B
BUILDING CODE SCOlTLAW/PROULEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a.) the Applicant, and (b) any legal entity which haS a direct ownership interestin Oie Applicant fc.VCC*:ding 7-5 percent (an "Owner"), ll is not to be completed by any legal entity which lias only an. indirect ownership interest in l.hft Applicant.
Pursuant to Municipal Code Section 1»154-010, is the: Applicant oi' any Owner identified as a building code seofiTaw or probletn landlord pursuant to Section 2-92*4 16 ofthe Municipal Cede?
If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of llic Applicant identified a$ a building, code seoftlaw or problem landlord pursuant in Section
16 of the Municipal Code?
___QY^ __Q_Np_ j^j Not AppliehMe
tf yea to (I) or (2) above, please identify below the mime of the person or legal entity identified as a building code scofflaw or problem Itmillonl and Ihe addressofthG building or buildings to which the pertinent code violations apply.
FILLING OUT THIS APPENDIX Ii CONSTI'l 0TES ACKNOVVLCDCMEST AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO. AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT TUB RJEPR.ESJ£N"rA7'J'OiVS MADE IN TUBS APHiNDIX It ARE
swatec? to me ccrtiwcation made under1 penalty of
PERJURY ON PACE 1.2 OFTHE ASSOCIATED EDS.'
\\&. 54 ot t-t
CITY OK CHICAGO ECONOM IC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name ofthe Disclosing Party submitting this J.-OS. Include d/b/a.' if applicable: CA KesKtoubl. i.f.r
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
f ] the Applicant
OR
f,vj a legal entity holding a direct or indirect interest in the Applicant. Stale the Ictral name of the
Applicant in which the Disclosing Pany holds an interest; 11,1ft Somh Wphadi. UjC
OR
3. | ] a legal entity with a right of control (sec Section 11.11. i.) State the legal name ofthe entity in
which the Disclosing Party holds a rigbt ofcontrol:
B. Business address of the Disclosing Pany; 161 N. Cfad: Sl. Sink- -191X1
Chicago. SL 60601
Telephone; 317 Fax; Rmail: jatouitoS^aia^^tiixoJ!}
Name of contact person: Rcifamfca it. Amsta
Federal Employer Identification No. (if yon have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") io which this EDS pertains. (Include project number and location of property, if applicable):
I'bjnnrd Development for 113i» - AO S. W:ii.:islt^6 I!. itw.arvcli Kd.
G. Which City agency or department is requesting this EDS?_ _ DPD
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Spccificalion it- and Contrac( fl _
Pauc 1 of 13
.SECTION Ii - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OP Til!.- DISCLOSING PARTY i. i!:::i<:;:iC ihe: rn:imrc oi" the Drsidosinj" f*:>r
i ] Pci-ivn
'¦ ! Publicly registered business corporation
[ j Privaidy held business corporation
i j Side proprietorship
General partnership
[ j Limited piirtuersh?,':
\ \ Trosl
|\j Limited lability-company
I | Limited liability partnership
[ ] Joint venture
( ] Not-for -profit corporation
(Is the not-for-profit corporation also a 501(e)(3))?
f 1 Y::~. " | J No
I ] Other (please specify)
1. For legal enlitie.-:, the state lor foreign country) td* iocOTpOyatiou Of organr/ntion. if applicable:
i. For legal entities not organised in the Stale of illicots: Has the organization registered to do business in the State of Illinois, as a foreign entity?
!N} Yc:- i J No [JN/A
B. ?F TI! £ DJ S C L O SIN O PA RTY IS A LEGAL ENTITY:
I. List below the full names and titles of ail executive officers and all directors of ike entrty. NOTE; For uoS-for-profit corporations, also list below all otenibcni. ifany, which ore legal entities. If there are no such members., write "no members.3 For mists, estates or other similar entities. Hst below the legal titfehoSden(s).
If the entity h; a genera! partnership, limited partnership, limited liability com pany, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manages or nay ether pcrsc-D or entity thai controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below jnust submit an JiDS or. its own behalf.
Name
('a titan-wr. IXC
2. Please provide the Following in formation concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess oI*7.5% of (he Disclosing Party. Examples of such ao interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13
irv.'.Tcsi ol a member or in:>*'i::>>>¦;~ iii :i limine! Iiubiiny company, oi niteres! ot a beneficiary ui .ri u estate or other similar entity. If none, state ""None."' NOTE: Pursuant to Section 2-l5-*-O?0 of the Municipal t 'ode ot"Chicago i"Mi!mc;p:ti Code"). :he City r.iay rcqvt-o any .such :u!diUe:stii ivUieh is reasonably intended to achieve fuii disclosure.
\ii:ne iiusmcsi; Address Perce n:a£e Interest in the
Uiscloshjg Parly
•:" \ '.fentizrw H«iiini»;, l.rx" iM N. CUsk .St Suite -S'XiO. Chjsga. II.iXMj_ IC<«i
SP.CTlON (II - Bl-SINK.SS RELATIONSHIPS WITH CITY KI.liCTE') OFFICIALS
•las the Disclosing forty had a "business relationship," as defiticd in Chapter 2-150 ofthe Municipal Ci.o'c. wilh any City elected official in the 12 months before the date this liDS is signed?
i i Yes (-JNo
if ye*, please- identify below the narac(s) of such City elected officials) and describe such rclatinnshipis):
SF.CTION IV - DiS CLOSURE OF SUBCONTRACTORS ANII OTIIKR RETAINED tM&TlKS
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party lias retained or expects to retain i« connection with the Mailer, as well as the statute ofthe relationship, tnnl the total amount ofthe fees paid or estimated lo be paid. The Disclosing Parly is not required to disclost employees who arc paid solely through the Disclosing Parly's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on beltair«f any person or entity other than: (I) a not-for-profit entity, on <
If the Disclosing Party is uncertain whether a disclosure is requited under this Section, the Disclosing Party ran:-: either ask the City whether disclosure is required or mtike the disclosure.
Pas-c .»of 1.1
-W.r.u: (indicate v/hethei Business Relationship io Disclosing Party !;ecs j*««!d?« •«««:: warmer
retained or aritieipatcd Address (subcontractor. ctUoincy. paid or estimated.* \UT1.:
:r> he retained) lobbyist, etc.) "hourly nnc" or "t.b.ci." i:-.
sto! an acceptable response.
(Add sheets if sisee-ssary)
rS-\ Cb-.: :'y: here if the Di*c'«sii»»j. Puny lias not itiaincd. nor expects io retain, any such pcrsotis or eut ::*•«>.
SECTION V - CERTIFICATIONS
A. COUHT-ORDERCD CM 11,0 SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-4)5. substantial owners of business entities that contract with, the City must remain in compliance with their child support obligations throughout the contact's term.
Has any person who directly or indirectly owas 10% or more; of the Disckisimi: Party been declared in arrearage oa any child support obligations by any Illinois court of competent jurisdiction?
{ ] Yes~No'[ ] No person dire^ 16%'or tan re'Of die
Disclosing Party.
If "Yes." has the person entered into a court-approved agreement for payment of ali support owed fci'd h the person in compliance with that agreement?
I | Yes [) No
53. l-URTiJi-R CliRWlCATrOiVS
t. Pursuant to Municipal Code Chapter I-23, Article t (""Article Pjfvvhrcb the Applicant should consult fordefioed terms, {c.§., "doing business'-) and legal requirements), if the Disclosing Party ¦stibmiuimj this liOS is the Applicant and is doing business with the City, then the Dtsclosiog Party certifies as follows: (i) neither tlte Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of. or has ever been convicted of, or pieced under supervision for. any criminal offense involving actual, attempted, or conspiracy to comtuit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City 07 any sister agtncy: and (ii) she Applicant understands and acknowledges that couipfiattcc witii Article I is a continuing requirement for doing business with the City. N'OTF: If Article I applies lo the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 ::nd 3 below.
?ap,c 4 of I
1- The Disclosing Party and. it the Disclosing Parly « legal cwtiy, a5! of sho-:c persons or critic-, idenuheci in Section U.B.i. of diis j-DS.
sv. no! presently ddi.'urcd, suspended, proposed for debarment, declared ineligible oi vijiuuuniy excluded from any transactions by any federal, stole or loc:d tm>: of rtovevtiinetn.
ii. h.i-c not. wilhin a :ivc-ycar period preceding the dale of this iil>U. been convicted ot .-. c;::nm::: offense, :»dji:dv;iMl uuiliy. obtoiu. or jjcrfotiiiinitpublic (federal, state or local} transection or cotitiact under a public transaction; a violation of federal or state nntttrust statutes: fraud: f i:d:x;jc\f,lL;in<;r,i; itit:fi: for$ei y; bribery; falsification or destruction of records: making false statements: or receiving stolen property.
arc not presently indicted foi. or criminally or civilly charged by, 3 governments! entity (federal, state or local) with committing any of the offenses set forth tn clause l.i.2.l>. of this Section V;
h::vt; not, within a five ¦¦yea: period preceding, the dale of this UDS. had one or more public transactions (federal, stoic or local) terminated for cause or default; and
c. have noi, wirhin a live-year period preceding the date of this liDS, been convicted, adjudged guilty, or found iitiblc in ;t civil proceeding, or ii4 any criminal or civil action, including actions concerning environmental violations, instituted by the Cily or by the federal government, any jitfsic, or aasy other unit of local government.
3. The certifications in subparts 3. 4 and 5> concern:
- the Disclosing Party;
* any ""Contractor" (meaning any contractor or subcontractor used by the Disclosing Puny in connection with the Matter, including but not limited io ell 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 coulioi of nimlbur 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 eattity following the ineligibility of ji busings entity :o do business with federal or state or local government, including the City, uxiiiji substantially the same management, ownership, or principals as the ineligible entity): with towed to Contactors, the icmi Affiliated lint'rty means a person or calhy that directly or indirectly controls the Contractu!, in controlled by it, or, wish the Contractor, is under common control of another person or entity:
- :iiiy responsible official ofthe Disclosing Party, any Contractor or tiny Affiliated I'jitjty or any other official, agent or employee of the Disclosing Party. <"»y Contractor or any A HHia-cd l-jtiity. ;H:lj.a£. pursuant u-, the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated finlily (collectively "Agcois").
Page 5 of 13
N'fiihr.r lisi: Disclosing i'r.ny, nor any Contractor, nor#nv Af'ilutda! F.ntity of cither the Dtsck'Sinj: f *.«riy n; :t.-iy Contractor nor r.:i\ Agents have. ilurinL* the five vcat'.> be Sore ihe dale this LDS is signed, or. with respect U"; a Cor.tractor, at! AITiliated iimjiy. or an Affiliated F.ritiiy '.if a Contractor durinK thi- f"-v. yc;i:r i:-:f
». bribed or attempted to bribe, or been convicted or adjudged guilty of bribe iy or attempting w bribe, a public officer or employee- ofthe City, ihe State of Illinois^ or any agency ofthe icderal government or of any a tale Or local government in the United States of America, in (!:.:: i ofrit:--;'^ w employee's official capacity:
a creed or colluded with other bidder* or prospective bidders, "or been :t parly !o «oy such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders >¦•¦ prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or i>lbcmade an admission of such conduct described in. a. or b. above thul is a mutter of record, but have, not been prosecuted for such conduct: or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
•1. Neither the Disclosing Party. Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is burred from contracting with any unit ofstnte or local government as a result of engaging in or b-inft convicted of H) bid-rigging in violtnioo of TM) U-CS 5/33P.-3; <2) bid-rotating.' ;n violation of 720 LLCS 5/33E-4; or (3) nny similar offense of any stale or of lite United Suites of America I hat contains the s-amc elements as the offense of bid-tigging or bid-rotating
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists «n a in last i ed by the Office of Foreign Assets Control ofthe U.S. Dcpsflmwu ofthe Treasury or the Bureau of industry and Security of the U.S. Department of Commerce ox their successors: the Specially Designated Nationals Lis!, the Denied Persons List, the Unverified List, the Isstity List and site Debarred List.
The Disclosing Patty nnderstands and shall comply with the applicable reriuittKOcms of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector Gc«cml) and 2-156 (Governmental litotes) of tlsc Muntcip.il Code
If the Disclosing Party is unable to certify to any ofthe above statements in this Part tf t Further Certifications), the Disclosing Party must explain below:
Page-6 of I"
If-in: letters "NA." the word *Nn:ic," or do response appears on she lines above, is will be conclusive-;, presumed that thr DijiciosiiiK Pruiy ccrtificG to the above system cms.
K. To the best of (he Disclosing Party's knowledge aftes reasonable inquiry, the following is.:; complete fist of ali current vriiploys-.es uf the Disclosing P;:rty wliy were, .it any lime d«.«-':*»s the iJ-inumn period prt-f-iin^ the e.vccerion dale of this F.DS., an employee, or elected or appointee «»i:fir:>->.». of ihe City of Chica-jo ! if none, indicate with "N
Mono _
9, To the best ofthe Disclosing Party's knowledge after rcinainablc inquiry, the following is ¦¦: complete list of oil gifts that the Disclosing Party ha* yiven or caused to be given, :u any time dunng the 12-month period preceding the execution date of this >.il>$, to an employee, or elected or appointed official, ofthe Cfcy of Chicago, l-'oi pusposcs of this statement, a "gifT dues not include: (i) anyt^ng made- generally ttvaiiablc- lo Cily employees or to the general public, or (ii) food or drink provided in Uk: course of official city business and having a retail value of less than S20 per recipient (if none, indicate with -'N/A" or ""none"}. As ?o a.oy gift listed below, please also list the name ofthe City rocipien-.
None
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
Tire Disclosing Party certifies thai the Disclosing Pwiy {check one)
I | is Pi is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"Wc are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none ofour affiliates is. and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code We understand thai 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 (.'sty."
If the Disclosing party is unable to mate this pledge because it or any of its affiliates (as defined in Section 2-32-455{b) or the Municipal Code) ii a predatory lender within the weaning of Chapter 2*32 ofthe Municipal Code, explain here (attach addition ;i I pt9vt.es if necessary):
Pace Vol' 15
if she K;ii'-".;s "NA." ihe word "None." or sin response appears on the tines shove, il wit! be conclusively presumed tbr.t the Disclosing Party certified to the- above-statements.
D. CERT! i;i CATION REGARDING INTEREST IN C1TV BUSINESS
\::y word:; or icrnts tfc.tl ure defined in Chapter ?-156 ofthe Municipal Cod" l*.nve the sum-.: meanincis %vJutn used in ibis S'.'irt D.
5. Iu t'ccordime'-: ''-'ilh Section 2-356-i 10 ofthe Mtiuiuipa? Cod;:: Din-s ;iny oTfiej-.d m empir-vee of the City have a financial msercst io his or her own name or in the nnmc o! any other person or entity in ti.ie Matter?
! ) Yes W No
N'OTR: Ifyou «;bia;S;ed "Yes" to Hctn f.). Iproceed to Items D-2- n«d D.3. Ifyou cheeked "No" to item D.l proceed to Part il.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City cicctttd official or employee shxU have :i fiiiauci;ii interest iti his or her own name or ir: the nasie of
Does the Matter involve a City Property SttlcV
| ] Yes [ | No
If yon checked "Yos" to Hera 0.1, provide tlte mimes and business addresses of the City officials or employees having st«ch interest and identify the nature of such interest:
Nome business Address Nature of Jnierc*!
4. The Disclosing Party further certifies tltttt no prohibited financial istien^t in the Matter will be acquired by any City official or employee.
K. CERTIFICATION REGARDING SLAVERY liRA BUSINESS
Please check cither >. or 2. below. If the Disctosfng Party checks 2 the Disc-losing Pany must disclose below or in an attachment to this? EDS nil information required by paragraph 2. Failure to
PasyrSof t3
:or::piy wnh these disclosure requirements may make any contract entered hi to with m c>>'.'.;icc!;"» :: lib ill.: Matter voidable by the V'ily,
X r. The Disclosing Parlv verifies that the Disclosing Party has svaielied aay and all records of •J-.c Uiseli.v.snj; l';;;iy and any and predecessor entities regarding records «f invr/siriicnu: cr profits from slavery or slaveholder insurance policies during the slavery sr.* (including insurance pohcics iist.e:: to slaveholders that provided coverage for damage to or iajury or death of their slaw:-). ;---nd the Di&ciosing Parcv has foimd no such records.
2. T.'C Disclosing Party verifies I hot. as a result of conducling the search in step 1 above, the Disclosing Pany ha.-: found records of investments{,; piofils from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all ttuch records, including the names' of any and all slaves or slaveholders described in those rvcoid>
SlCCTlON VI - CERTIFICATIONS VOX FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section V{. If (he MatU-r is om federally funded, proceed to Section V ll. For purposes of this Section VI, lax credits allocated by the C»ty ass-d proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
I. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying con-nets on behalf of (he Disclosing Party with respect to the Waiter: (Add sheets if necessary);
(If no explanation appears or begins on the lines above, or ifthe letters "NA" or if the word "None" appeal, i: will be conclusively presumed thai she Disclosing Party means that NO persons or entitle-, registered undci ihe Lobbying Disclosure Act of 1°95 have made lobbying ainiatLs on behalf of the Disclosing Party with respect to the Matter.)
2. 7 he Disclosing Parsy has ant spent and will noi c*p«.-nd :tny federally appropriated funds to nay 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 lo influence an office? or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an t:»iploycc 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 estend. continue, renew, amend, or modify any federally funded contract, grant, ioan, nr cooperative agreement.
Page
j. : 'k: Dixc'tfiiii;.- Pany v.;;', submit mi updated ecr: ilka! ion 2S u:^ tin! '.it :.:::i;f: itaiera;:!!' :;¦•>2r wi'iich there occurs any event that materially affects the accuracy of she :;talt:me?il.s and in fort-auto forth iu paragraphs A.l. and A.2. above.
•!. The. Disclosing Parly certifies thai either (>) it is noi an organization described in section 501 (c)!.4) oi the inlet »al He venue Code of lOfco-; or (ii) it h an organization described in section 501 t of the Interns? Revenue Code of 19x6 but has not engaged and v.-ill so? ci'.ftwy U: "Lohcysnc Activities".
5. If die Disclosing Parly is the Applicant, the Disclosing Pttrly muss obtain certification* equal ir» form and substance to pa-ttgraphs A.L through AA above from all subcontractors before it swards any subcunfitici ami the Disclosing Party must maintain till .such siibeontf actors' ceraficatitj":? f«u- the duration of the Matter and must make such certifications promptly available to the City upo? request
B. CERTIFICATION 'REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and nil proposed subcontractors lo submit the following information with their bids or in writing at the outset of
ozonations.
ls the Disclosing Party the Applicant?
f J Yes | ) No
If "Yes." answer the three questions below:
}. 1 lave you developed and do you have oft file affirmative action proglottis pursuant to applicable
federal regulations? (See <* I CFR Pan 60-2.)
i i Yes {} No
Have you filer! with the Joint Reporting Committee, the Director of the Office of I'edcrn. Contract Compliance Programs, or (he Equal Employment Opportunity Commission, ail reports due under the applicable filing requirements?
L j Yes j ) No
l-fave you participated in any previous contracts' or subcontracts subject to the equal opportunity clause?
{] Yes ' [ ] No
If yum cheeked "No" to question I. or 2. abovt:k please provide an explanation:
Page 10 of l>
SECTION V.'» - ACK'\0\\rLGUCiVlKNT.S,<;.ON'r^AC'«' tNCOftPOftA'lTON. COM P E 5AN<• E» PEN A I. TIES. DISCLOSURE
'I'lic Disclosing Party understands and agrees that:
i"lie ccrtiftcaucas. disclosures, and acknow icdgmtnis contained in this EDS will "become pan c>; an> i.*ori::'ici or ni):-:-c :i:-.;t:Cinciit b'1'.i'ta-ii tin: Applicant arid tin* City CKPfiCCHon v. :>U iht' Matter. wStr-:ric.; procurement. City assistance, or other City action, and are material inducements to the City's execution .tt'ar.y ciiiv.iai.-: m taVin;.: oth-.:i action with respect to ihe Mattel. The Disclosing Party understands thai it itiii-a comply w«h all statutes, ordinances, and. rcgubtions on which this EDS is based.
The City's Governmental P.iitu:-; and Ctnnpaign Pinanving Ordinaiiccs. Chapters J 56 and VS of ihe Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is av&ilahte on line at w::• w.eityofi;hie:ii>.o.,Qfs/Btbicx and njrsy ;jl:?o be obtained from ihe City's Uoard of Ethics. 74 () N.
Scdgxvicl: St Suite 500. Chicago. IL 60610. (2*\2) 7-14-9660. The Disc losing Party must comply fniiy will; the applicable ordinances.
if the City determines that any information provided, in this EDS is false, incomplete or inaccurate, any contiact or otlna agreement in connection with which it i.s submitted may be rwsciridcd or he void or voidable, and the Cily may pursue any remedies under the contract or agreement (if not rescinded or void), at law. or in equity, including terminating the Disclosing Parly's participation in the Matter 2!id/or declining in allow the Disclosing Patty to participate in other UaiiSSr.tioii.-; wilh the Cily. Remedies til law for a false statement of materia* fact may include incarceration aud un award lo the City of treble damages.
It is the City's policy to make this documem available to the public on its In tern-.:'< she and/or upon rcqvest. Some, or all of the infonnation provided on this EDS and any attachments io this EDS may be made available to the public on the Internet, in response to a Freedom of Information Acl request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in ibis EDS and also authorizes the City to verify the accuracy of any information submitted in ibis EDS.
The information provided in this EDS must be kept current. In Ihe event of changes, the Disclosing Party mus? supplement this EDS up to the time the City takes action on ihe Matter. If ihe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update ibis EDS as the contract requires. NOTE: With respect Jo Matters subject to Article 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELlGtfiCMfV foi certain specified offcuscs), the information provided herein regarding eligibility must be kept current for a longer period, as reqyi.ed by Cbfipier U23 ;wd Section 2-154-020 of ihe Municipal Code,
The Disclosing Party represents and warrants that:
Pac-e 11 of 13
'¦¦ ¦ The Disclosing ?':;rty I.-; not delir.oucut 5:1 ihe payment of any U\\ itdi^tM^cs'ce by ;.i;c i:.:.;?!ot.-Dcpartmenj ol' Revenue, nor arc the Disclosing Party or its Affiliated Entities d-.-!tnq«:eiii is> p.-: vine iiitc. iee-. tax o? other chaige owed to the City. This includes, bm is not limited to. ais water charges, .'.ewer eh.vgesi. license leva, parkin;:; tiekcls, pwperty taxes or sales taxes.
!-:; il the. Disclosing Party is the Applicant, the Disclosing Party and its Affiliated lint sties will not w*c. nor permit their subcontractors to use. any facility listed by the U.S. li.P.A. on tb? federal F.xc:uik-<< P.iiiic^ List System ("s-iPLS") main mined by the U. S. General Services Administration.
*"'-•» lft.be Disclosing Party is the Applicant, the Disclosing Party will obtain frtun any siontraciors/siibcontractors hired or to bs hired in connection with she Matter ccrtificatiotas eauai n-form nnri substance to those in F.l. and F.2. above and wiil «oi. without the prior written cimr.cni of she City, use any soch comrniclor'sufecontractor that docs moi provide such certiljctirio-ns r>; that tic.-Disclosing Pany lias reason to believe has noi provided or cannot provide truthful certifications.
NOTJi: If the Disclosing Party cannot certify u$ to any of t&c items in F.L, F.2. or above, an explanatory staiemciti inusi be attached to this KDS.
CTiRTil-iCATION
Under penalty of perjury, the pcreoa signing below: fl) «rctrra»ts that he/sbc is auihorixed to e-x-.-cutc this EDS and Appendix. A (if applicable) on behalf of ihe Disclosing Party, and |2) warrants that all
ecrtifieaSioni; and statciacats contained in this F.DS :;n;d Appendix A (if applicable) arc tit;;:. acvMtraie
and complete as ofthe date furnished to ihe City.
rtcsltfcntics. LLC t/'rtnt or type name of Disclosing Party)
4 S?gn here)
7 Iwiass M Scot?. (Print or type name of person sighting)
hfeqgiaft Maiinher oI'Maiiftfiw fPrtal or type ntlc of person signing)
Signed and sworo to before me on (date) / 0 , >**i 5
at _Oagi County, Eft'ois _ _ (stale}.
H / / (j-y<- ¦¦:.:^r-xZr-::-c^=^ Notary Public.
iu '¦
Commission expires:
Page I ?. of I i
*^>*T' >-#«-.•. » ... * ( )
crrv n-r chicacg
KCONOMH': MSCi.OSURK STATK.MF.NT AND AFFIDAVIT APPKNUiXA
FAMii.jAf./ RF.I-ATiONSmi'S WITH Rl.f'CT Ei> CITV OFFICIALS AND DEPARTMENT He ADS
This Appendix is to be complfcled only by (a) th£ Applicant, and (b) any legal entity v.bieb has - direct ownership interest in the Applicant exceeding 73 percent. I't is not to be completed by any legs! entity which has only an indirect nwnership interest in the Applicant.
Under Municipal Code Section 2-154-015. tits Disclosing Party muss disclnsc whether such DiadtiSing Pan;, or any" Applicable Party** of any Spouse or Domestic Partner thejcof cwwutly has a "familial n^atiu:vj:lup** with any d"Applicable Pany" means (i > all executive ollkers ofthe Disclosing Patty l':.ied in Section il.B. 1if the Disclosing Party is: a corporation; all partners ofthe Disclosing Party, if the Disclosing Ittrty is a general pirt:>crship: all "ejicral partners and limited partner-; ofthe Disclosing Party, ifihc Disclosing Party is a limited partnership; all managers, trctnaging members end ntetnb::rs ofthe Disclosing Parly, if the Duichuuug Pn.-ty is a limited liability company; (2) all principal officers of die Disclosing Pany; arid (3) any person having mure than a 7.5 percent ownership interest in the Disclosing Party. *'Prbs;ipas officers'* means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Docs the Disclosing Party or any "Applicable Party*' or any Spowtc or Domestic Panne* thereof currently have a "familial rcUittouship-' with an elected csly official or department Head?
i j Yes [XI No
If yes, please identify below {1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected: (.->) the name and title of ihe elected city official or department head to whom such person kis a family relationship, arid (A) the pjecrsc oati-ft of such fiuuiltal icJariotKhip.
Page i 3 of 13
ECONOMIC DISCLOSURE ST A Tfc'M K*iT A NT? AFT-'UU.vn
APPENDIX B
HviLDlNa CODS SCOFKiLAW/PROBi,KEv| i«ANDLORD CHl'TtFJCATlON
This Appendix is to oe completed on!) by {;j> the App'ica-u antf ¦ b} an? kfn-l -nitty iioch bus a riirecr ownership interest ic },b.t Applicant exceeding. 7.5 JK-rt:c:;: {-.rn "Owij-.A «ot to t>c eontfslcfe.^ bj any liogu; caaty which: &&s traly aa r-nsSircct owoersbip interest in e-Applicant.
!. Ptnvurm; io Municipal Cocfc Section 2-1 >M)$0r is die Applicant or any Owner idc-aitficd as building code scofflaw or problem landlord pursuant lo Section 2-Q2-411\ oft»«e- V*u»»-"fp2: Code?
i |V« JXiNo
I if'ihe Appiiaitt is tr. legal entity purely Utided un any exchange, in ;.ny crKcer or rfirecw i. •Jjc Applicant identified as a building code soofflatv or problem landlord pirrsiiani ro Sec-tin 1^2-41 fi ofthe Municipal Code?
f lYcs I JNo IXI Not Applicable
;fyr> rr* vl) or (2; shove. p5ca.se identify below the name of the person or tcgal emtry identified as s buildrnrj code scofflaw or problem landlord and ti» address nfthc building o. ivuildings to u-ftich the pertincn! code violations ttpplv.
FH.UXG OUT THIS APPENDIX & CONSTITUTES ACKftWLKDGfHKKT AND ACITY OK CHICAGO £CONOM IC DISCLOSURE STATEM ENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of Che Disclosing Party submitting, this EOS. Include ri/b/ri/ if applicable: I ] .\ t> South WviKisii,
Check ONE of the following three botfesr
Indicate- whether the Disclosing Party submitting this EDS is:
1. |xJ the Applicant
OR
2, | j a legal entity holding a direct, or indirect, interest in the Applicant. State the- legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
\ J n legal entity with a right of control (see Section ll.B.l.) State the legal name ofthe entity io
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Parly: tot N. dak St Suite 4Oueiyo. 11.60601
Telephone: i 12-636-6937 Fax: Email; jyjOT00S-iaiajaaca3jr.com
Name of contact person: Rolando ft. Acoga
Federal Employer Identification No. (if you have one):
Brief description of contiact, transaction or other undertaking (referred to below ns tttc "Matter") to which this F.DS pertains. (Include project number and locution of property, if applicable):
Plained Povciojxijcm for 1136 - 40 S. Wabash/26 Ii. Roosevelt Rd.
G. Which City agency or department is requesting this EDS? DPD
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract it
Page 1 of 1j
SKOTION ii - DISCLOSURE OF OWNKRSKIP INTKftltSTS
NATUfti: '¦>>' i'Hr; DISCLOSING PARTY
i
[:i.!ic.'i!c die :i.i:ir'f
[ ] t'.rt: -,
f 1 r»»il>lic!y ic&istcred business corpora; ion
( I P.-ivii-rely heid basinest; corporation
; ] Side -;o;::-ictor-hit>
! } Oeaeral (Vsr-iiirndiip
[ J c.::ji;!::d piijlui^ljir.
( I frost
JXl Limited liability company
J ] itsibiSiry p^r'u-jri'tup
i j Noi-for-profU corporation {Is ehe ooi-fai-profrt coipor.-irjon a!>o a 50l?e)(.;)f
Kiir legal cuiiliiis. t5ie stslc fctJ foreign country) of iocorp!:. rf £•-•,':rtb
Minor,
i. For fegal cnCflks r.m orgtusi/isd tn tho State of Illinois: 'nan the orj^niAattiiri negr&tned io do buniasss its the Slate of Illinois as a foreign entity"?
M N/A
ii. IF THti DISCLOSING PARTY IS A l.KtfAL B1VT1TY:
1. List below the toll itamcs and ittle* ofall cs.cc«tive officers and ali director; of the entity. NtVTg: for jiot-fot-profii corporations, also list below all members, tf any. wbich arc legal entities. If there are i::) raich ntt-siber;. write "no members." For trti:;!*, estates or other siinttar entities, i::;t below the Jegui titleholdcrfs'}.
H'tiiC exaiiy to a general psuir.crship. hmrted paiuteisbip. Untiled liability company. Hn»it.cd liability partnenaiip or joint vc.ntu.ic , list below the nunc and title of tacit gccezal ntnincf. n:aaajia^ rticnferr. i:t:i:i?f.eroi ajiy oiiter person or cntiiy that controls the dayta-eay niajiageinent of toe Dtedo.-dng Party. NOTE: liach legal entity listed below must .submit an CDS on its own behalf.
Nartie Title
tCcit!> t tii;-,i Mca^sr
2. Plciii.-. provide ihe follow ing «oforakatM>n coocevntng each person ©? cmhy tun-tog a dtrsjc? or indirect bciidTCial interest fitictudaon ownership) in excess of 7.5% ofthe Dux toiiiog "arty, li.vii;iis:i::; of;ttb an interest include sitarct; in a corporation. (Kutitsjjthip interest in a partnership or joint venture.
fVlJ'C 2 of I
!?iU:n:.s! o; .'; ltirtnbcr '.J! nuwagei iu .1 )i~>[U.i.l hsbiifty cote easy, or ii\'t>; ::::¦>. of :i be;:--- i':::;:!:y nj a trust, estate i?j oiiicr similar entiiy. i( aoi»e. stale "None." NO TIC: Pursosnf !o Section - i 5-1-U38 uf :hc Mu.'!!!-.:;iri! > •. ,.V nf Chicago (".'--fc!Jiivrp;:I Code"!-, !';:: Ciiv rjl:iV :v.:;is;rc arty .»!:rh .¦•¦:;r.;ii«j:vi!i :r::"'.i:i'::;!:;i^r. :VoiVi J.iiy pplhrauS which is ic::;ii:vnn)y intended 10 achieve i'M discioAi:rc
PcftcnCijic in'.cr-r.l ;:i the Disclosing f'.^ny
CA.X>': HXitti y.ixxk )¦•. i.i.C 161 N < "tasK S4. Suae J'Jim. i.lncqs* ;•!. «CWi
SKCTJTON UI « BUSINESS RELATIONSHIPS WITH CITV r.LKCTlCD OI-TKtAl.S
Jins tbe lJir.c£osrfl:j; I'arty bad* a "business iclabotwbip." as defined in Chapter 2-lift of the- Municipal Code. »viih any City o'cetcd official in ibe 12 months befo?<; ih* da:-.- this J:.!tS a- sugard?
! 1 Yes
if yes. picssi: identify below the uarnej*) ofsuch Cily elected officiiJ(s) and describe tarch rcl.itionslvpfs):
SUCTION IV - DISCLOSURE OK .SUBCONTRACTORS AM) OTHER RKTAI.MCO PAttt'ilC.S
The Dwelo.vtng Party :nusi disclose the name arid business address of catch subcontractor, attorney, lobbyist, accountant, consilium aitd any other j>erfcoii or easily whom the Disclosing Party has rcianscd or expects to retaiti in connection with die Mailer, is well a.t the nature of in** relationship, and tbs nnnl amount ofthe fees paid or estimated te be paid. The Disclosing Party is not required i« disclo::" ciwpUjw.es whu are paid soEcly through the Disclosing, Parry's regular payroll,
'"I ohbysst." nteans any person or entity who underttvkc* to influence any tc?.*slntivc or administrative, action on behalf of any psrsors Oi entity oilier th?.?,: (I) a nos-for-profit eniity, on on unpaid basis, oj {%) himself. ^Lobbyist" also means any ptrsoo or cnJjty any past of whose dude* as ac employee of another snelncvs undertaking to influence any legistaltvc o: arfmisbuativc action.
If the Disclosing Party is uncertain whether a disclosure is rcqisu-ei! wider this Section, the Disclosing Patty jnu
Paja: of 1J
*3!t?tr '. :r I\".:\\c v, hi ii;:vne*S Krtatrotisiiip to Disclosing F\triy Pecs (indicate whether
tela toed is; anticipated Address (subcontractor, attorney, paid «.\-!i;n.-,icd J XO'i'f":
tn be {tjaincdj lobbyist.
Rctcaa! !?>. i?*9 W. Urir-iijcy St Obir.ico, lt.fcOti--1' A.:;) SStl Uftll ifjt'il
(Adi! sheets if rteccKsary) (
t i Chce!. :icrc if the Disclosing Parly hits not retained, nor expects to retails, any psich pciston;: «>r entities.
SECTftJN Vr - CERTIFICATIONS
A. COURl'-ORDeSEU CHILD SUWiRT«)MPtlAiMCli
Under Mnokipo! Code Sccliei; 2-92-4(5. substantia! owocrs nf bonnes* cntKtcs d.:»: eiitifnu'. v-ah thi- City rmist remain in compliance witb their child support obligations !ljroyg,lvou! the. conuttct';; term,
Jlas any pciso:i vrh© directly «r indirectly owns IQ% or more of tit a Disclosing. Puny been declared tn arrearage on any child sunpor; obligations by any U!::u>:.s court of competent jurisdiction?
| LYcs fof}-No— —~H~^o person diroTsry or iiidlYceniy (wii7n'0V^6rm3Fc^>f die
Disclosing Party.
li"Ycs." hiii she person entered into a cotjri-appJovo<3 apreemcn! for payntcoi of all support owci.s she person in compliance with tha! agreement'.'
I ] Vcs [ j No
ii. PORTHi-R CERTIFICATIONS
1. Pursuant to Municipal Code Chapter i-2.). Article I f*Articf« l""j(wftich the Applicant skoisEd consult for defined terms (eg., "doing business") aod legal requirements), if the Disc losing Pony subtnitiiGt- this EOS is the Applicant cod is doing business with the- City, th«o. lite Disclosing Party certifies as follows: (j) neither the Applicant nor any controlling poison is currently Lr.or.etcd or c'ortrged weHi. or bs.i admitted yuilt of, or has ever been convicted of. ot p faced undci supervision for. any rriroioal offense Involving acniat, attempted, or conspiracy to cow nail bribery, (heft, feed, f«c£«y. perjury-, dishonesty or deceit agaiasl a* officer or onp.'oyee of the City or any sister agency: ami (ii) the Applicant undeotUiRdsiutd aukttowk-alncs that compliance wiib Articfe I is a continuing requirement for doing business with the City. NOTK; If Article i applies to the Applicant, the pcrmancTii coiaplisoci litiictYnmc- in Article 5 supersedes some fivcywr compliance timefrajiie.:i in certifications 2 and .1 below.
Page *1 of 13
The ! 'iseloMnf: F;.;;!'. :t:sd, rf the iJisclo.tiog Pariy \s a k":';il cainy. ait ofioi isc p-s: .«:»>' ':r CRM:-.*!:
identified i:i Section lUi i.ofdti* liDS:
:i. aie not prescti-lly dcbaricd. .niftpcudcd. proposed iu: debarment, dr.elarcd :i«cli;;ible 01 voliioiariiv excluded from an\ jfa::s:i::liops by any fodc/aJ. Stale of local m»l >»f govevvnem
b. have on;, within a five -year period ,7fetc?Mt:.:j ihe date of this F.DS. Ixtci* convicted of a cruotoai
,-:tf'. :ir;o. adja4t;cd frilly, o; had civil jau^tr.ent rendered incrn in connection wilh:
obloiitiiisj, attempting lo obtain, Of performing n public (federal. Statu it local) trarvwctH'rt or Contract under a public Uansactron; a violation of federv.S or state antiiryr-: statute;;: iV«iud; «nhc?zlciiivnt; '.hcii: forgery; bribery: falsification or destruction of rcconK-; making fa.i.w r.tatefSonl;;; or rceeiviitj; stolen property:
e. arc not presently tn-dirtcd for, or criminally or civilly charged by. a iw>vr.rr,n>cii!.'j! entity (federal. ;>iate fir local) wilh committing any of the. offenses set forth in clause fO.b. of ih:.s Section V;
d. have; Mot. within a five-year period preceding the dale of this Kt)S, had one i»r more pubt:c transactions (federal, .state or local) terminated for cause oj default: and
r have noi, whiii.i a five-year penod preecdrnr; the dale t>f this liDS. been convicted, adjudged j-uiliy. or found IsaVtc io a civil proceeding, or in any criminal or civil actioit, -.v.-.itiivtin^. action.', concerning enviromtacmas violations, instituted fay the City or by tfe« fodeta! government, any state, u: soy olher unit offoca! i^ovcmmcat.
>. The certification* in ttubpurtt 3,4 nod 5 concern:
- -be. Disclosing Party:
any ¦•Contractor" (mcatjinf; any contractor or subcontractor used hy thr- Disclosing Party it: connection with the Matter, inc lading bid not limited ta id) persons «r legal cnituc;: disclosed under .Section IV. "Disclosure of Subcontractors aod Other Retained Parties"):
at:;' "AfVriiotcd Emily" (meaning a person or entity that, directly or istditvetiy: controls the Disclosing Patty.is controlled by the f>iia:lo:rose?locking management or owuemktp: identity of interest.'i amorig family members, shared fwiliucs and equipment; common use of employees: or oro.anizotrou of a busiocs;; entity folloe.toy, the ineligibility of a business entity to do business with federal or ittotc or local ftovcrmncn!, including the City, using substantially ilie ;;amc management, ownership, or principals ss ihe ineligible entity), with tespect to Contractors, the term Affiliated IjnlUy nioans a pessan «? entity that directly o* indirectly contiols the Contractor, is controlled by it. or. wilh the Contractor. is under common control of soother person or entity:
any responsible official ol'the l>'tsclo.*iiu; Party, any Ontmeiuf o: .my AiTiiistcd lintity or any otlicr official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Kntivy. actinj: pursuant tn the direction or aull:ori/.aiion of a responsible official ofthe Ditsc losing I'aity, any Contractor or any Affiliated Tntity (tolleclivcty "A!jtjit»"V
Page 5 of )J
Neiifce: V'ii'clGS'.n;'. i'ariv. li-.vi'any Contractor. i:i>: ::ivy '.¦¦Tiliz'n:-.! i*tii<> •/fri-.hei l!:-:; .v.,::a' ieiii.y, fairy oi a;iy Coiili:!; !i:i; nor any Agents have;, durii::> the five y«;.-5 hci'ore ihe d~:c this H>S is signed, or. with respest !o a Contract nr, an A ffi tinted Entity, or tin A( jiiiaiee Mntitv of a i\>rirac;o.!' d tinny the :1 ;v .vcais be!>.«:• the date of such Contractor's or A f(ii:a;e.t5 fi;;tity's contract cr cajpgccicnt connection. v< iih die 'Amir:
a. bribed ot attempted to bribe, or been convicted or adjudged guilty of bribery o: attempting to
bribe, a public officer or employee of the City, the S«;ttc of Illinois. <>r any a.-;«icy of die federal
5jovermv.cnl.or of any itatc or Joeal government in ihe Unite:! State:; of America, in that oft jeer's
r employee's official capacity;
r\ S!;rec«! of eollodcd with tilhcr bicidctR or prospective- bidders, or been a pany to any such
st'refrinctit, or been convicted or adjudged guilty of agreement or coilitsion aiv.ors; bitidci-.- or pto.'.-pcvdvc bidders, in restraint of freedom of competition by ai;te<.:nciii to bid 3 fixed prise or otherwise: or
i:. tr.adc at; admission of such conduct described in u. or b, above that is a matter of record, but fsavc oo: teen prosecuted for such conduct: or
d. \ jointed Uii: proviciofis of Municipal Code Section 2-v2-6IO (Living 'A'aj^c Ordinance).
4. Neither the Dfcc-lostnjj Party. Affiliated Bothy or Contractor, ot any of their employees, olTtcbli;,
agents or partners, is hat red from contracting whit any unit of state or local s>-»verni:ietit a? a result of
engaging: in or being convicted of < I) bid-rigging in violation of 720 ILCS -V33E-3.X£liMdrf-vt»lattu3"ar7?01LCS •>/J31M; or (3) any simitar offense of any state or of the United State* of
America that contains the same clement.? as she offense of Wd-risK«ny. or bid-rotating
5, N ci tier she D isclosing Party nor any A (filiated iiatity is listed on any of t he fol tawing 1 ists
maintained by the Office of Foreign Assets Cotiuol of the U.S. DepctttJiicnt of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: djc Specially
Designated Nationals List, the Denied Person:; Us*, the Unverified List, ihe Kntity I i.iti ond the
Debaiitd List.
b. The Disclosing Putty understand.-? and sit-a!! comply with the applicable requirements of Chapters
2-55 (Legislative Inspector Genera J). 2-56 (Inspector General) and 2-tSfi (Governmental Ethics) ofthe
Municipal Code.
7. Sf the Disc losing Party is unable i*> certify to arw of t*>e abov« statements in rhis T'tsn I? (Further (.Vilification*); the Disclosing Parly must expt-'itsi below:
Page 6 of
Jf ihe letters ".MA." the ivord "S'onc." oi mu response appear.* on the Inies aluive. ft wii! I>e rorrl-.tsiver.* presumed thai the Disciosutt; Tarty certified to the above ::Ui;cntcni\.
S. To the best of lh:: Discio-suns* Party':; knowledge -Met r.::-.sor.;j ";>.'<; i!:qi:;ry. ;ir,c loilowwg :s .1 complete list of current employees of the Disclosing Parly who wctc. at arty time dortn?. the i 2-mc«:th period preccdi:i<; the execution dale of this i:DS. an employee., or elected '.'t j^-tuci¦¦!<:(! rdVict&l. of the City of Chicago (if none, indicate with "NV'A"or "noite").
s'--,,-.-.
'}. To the best ofthe. Disclosing Party's: knowledge after icasonshtc jncjuiry, l!-:; folio »\'iiii* a complete list of a)i lyfti- that she Disclosing Party has given ot caused to be juvco. »i any tnnc during the f 2-iiifitit.fi period preceding t?i».~ execution dale of this KDS. u> an employee, or elected e: appointed official, of the v-V.y of Chicago, hoc purposes of this statement, a ~gili" doe,-, noi include (t) anything made generally available to City employees or to the general pubiic. or (ii) food or drint; provided in the cout'-x- of official City business and having a tctai; v«t«c of less than $20 per recipient (it none, indicate with "Ni A" or "none"'!. As to any gift lisLed below, pleaits also litl the name ofthe City iccipiml.
IVonc .... ...
C. CERTIFICATION OT STATUS AS FINANCIAL INSTITUTION
The Disclosing Pany certifies that the Disclosing Party (check one)
[ ) is tX} is not
a "financial institution" as defined io Section 2- S?. 455(b) of the Municipal Code.
If the Disclosing Party IS o financial tnstiiuiioti, then the Disclosing Party pledge:;:
" We are not uud will not become a pTedatOry lender as defined in Chapter 2-52 of the Mun'tcipat Code. We further pledge that mine ofour affiliates is. and none of thesn wilt become, a piestatnry iender as detined in Chapter 2->2 of the Municipal Code. We understand thai hecotoing a predatory lender or becoming nn affitrtitr. of a predatory lender may icsult in lite lass- of Ibc n rivileijc. of doing business with the City."
If the Disclosing Party ts unable to mage Ibis pledge because it or any ofhs dilates (as defined in Section 2-32-l55
f'ti-i-c 7 tjf 3 3
inc. ;:;:?fv -'-.•">, -- .vspon:;': ::;>p:e::;> un tLe tine* e. iii p. conclusively presumed that the Du.clostiig f'a,ity certified to tit:: shove Statements
U. CKRTlr'lCATIO* KBGARDfNG' INTI-R EST IN CITY
=\ny ''<'iils or u-rt:!* that sre defined ta Ctaqi'.ct 2-156 of the Niuotctorsf <.'«•»; ha v.: thr same ineinusiu'. when uwd ir* ibis Port D.
j. In aeeu;3:iae,e v, uh Section 2-r56-lift ot the Munic.-pal Code: Does any official oremployee oi' the City have ji financial interest in his or her own triune or in the :i.-:r,:.: of any other pe:::ij;i u-cattty in she Matter"?
I t Yes (;<] No
NOTf:. ifyou checked "Vcs" to Iu::!t P. f., proceed to Items D.l, and D.3. Ifyou cheeked "No" to Item D. 1., proceed to Parr B.
Ualcss .',-;i?d pursuant to :t procetw of cDocs ths- Viatic: involve a City Property Sale.'
f 1 Yes [ I K'o
Ifyou cheeked "Yes" to Item D.l provide the names and fctrsitiess addres5.es ofthe City officials or employees having »u«h interest and identify die nature of such interest:
Nsine ttitsincss Atblnsss Nature of Imcicit
¦V Tbc D loosing Vany further c'cAifte* that no prohibited financial interest in the Ma lief will be acqulied by any Cily official or employes.
f-:. CKRHKtCA nON RP.GAKDSNG Sl.AVIiRY ERA BUSINESS
Please cfeecA: either i. or 2. oxdou'. tflbe Diicfoitr:;.?. Party checks the DiMth^ivig ran* must disclose below or in an attachment to this EDS all infoimaiiou required by paragraph 2. Fuitute to
Pa^cSof U
:::>::::My M-iIh thes-.: <: enclosure .'CijinrcnuTiU; :.".:!•/ ni3£C any eor.K.K • eiitei eii i;;:v> -v.iii ilre City jn C04ir::c!t"n (villi Che Mailer voidable 'try die Cji>.
! The Disclosing Party verifies that thr Disclosia:'. Par;.; has .vsaichctf liv. and nil r ceo .'tis ot' the i lisclosuig P/i/iy ai:ri any and all predecessor entities regardiny, records >:¦!' j.-iv-.-sujieab. i;r profits !Vo;:; ::!av -;-y ix slaveholder insurance poheier. dunRg, the slavery eta (mctiidicj: fiiSuCanc.c policies :.-:>ued to slaveholders- that provided coverage fei dawai-c- lo or injmy or death -.>; their slaves}, and the Dtsck'MBg t'itty has found no such rccotds.
2. The Disciosiog t-'arty veftfic: that., ns. a result of coaductun;, the scare;: :n sirp ! above, the nisc'os:!;;; Party has found record:; of irvesimciiti ox profits Jiuiu »lavcry or slaveholder insurance policies. The Disclosiup, Party verifies that the fottowine, oousiiur.es full di.-w'.osorc of all such reicor:!st trtcludinif the atuncs of any ond all slaves or slaveholders described in lhui-c u-cords:
SUCTION VI - CKKTIFICATTONS FOR I'K OK RALLY RiNDKU MA VT%ii&
NOTE: If the Matter is federally funded, complete this Section VI. it the Matter is out federally funded, proceed to Secito:i VII. For purposes, of this Suction VI. tax ctciht; allocated hy »he City and proceeds cif deb; obligations ofthe City arc not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1, List below the namea vfall persons or en titter registered under tho federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Pany wilh respect io the Mattert {Add sheets if necessary):
(If oo explanation appears or begins, on the lines above, or if the letters "NA* or if the word. "None" appear, it wait be cosctusively presumed that the Disclosing Parly nteaiw that NO persons or entities registered under the Lobbyinxj Disclosure Act of IWS have made lobbying contacts on behalf of tha Disclosing, S'arty with lespeet to the Matte.,)
- The Disclosing Party has not spent and will oo: expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above fox his or her lobbying activities or to pay any person or entity to influence or attempt to influence aa officer o: employee of arty o^cii'-v. as defined by applicable federal law, a member of Congress, an officeror employee of Congress, or au employee of a member of Congress, in connection with the award of any federally fauded contrack making tiny federally Ituided grant or loan, catering into any cooperative agiciwocnt or to extend, continue, renew, attend, or modify any federally funded eooiract, grant, loan, or coopcxative agreement.
Pa<*°of TA
5 The f>iseli*sjr.£ Paity will submit an updated cortifieatior. .n the cud of each calendar quarrcr :n which there mteurs any eve at that materially affects the aecurac v ofthe ¦:!::ir-.-.Tic.!>i.-. ami lafopsta^ioo t-'e [\<;-.h rn^TJidv* A.l. a;>d A.j. abovi.
•!. "Hsu DtevSosifi;; Party cet^iie;: that tithes: (i) » is not ail utgaitr/Kiion described in section 5U i (c *(~) of the Internal Revenue Code of I*.':i6; or frf) it s an orfreofeatfon described i:i section ¦*0Hc)! '' of th:- Internal Revenue Cottc of 19S6 fetu hy.-jiat engaged :>nv, ivi'i! not engage to "Labbytn Activities".
5. If the Disclosing. Party is she Applicant, the Disctatrtng Party rata:! obtain cciiificat ions equal n fottji arid substance to paragraphs A.3. through A.jl. above from all srabcoeiravtcrs before it awards subcontract and the, Disclosing, Pony most maintain ail such subcontractors' certification? for tire duration of lite Matter and smut make such ccMtficntiojis promptly avn"liable to the City upon n.::riresi.
B CERTIFICATION REGARDING EQUAL HMPLOYMENT OPPORTUNITY
11 the Mattel is federally funded, federal regulations require the Applicant, and all proposed, subcontractors to Submit the following rnforpv.ltoii with ihcif bi'Js 0: «i \vTiti:i«; at tiic ur.i^et of negotiations.
Is the nis.: losing Party the Applicant?
""I ] Vc:,~t INo
If "Yett," 3ttE^'Ci the three tjucsiiuat: befou.".
!. Have you ttavctoped and do you have on J'de afrinnative act-mo progiaau; pursuant to appitcab
fedsfal rctjultitinits? fSec 41 CFR Port 60-2.)
( ] Yes | I No
Have you filled with (he Joint Reporting Committee, the Diiector ofthe Office of Federal. Contract Compliance Prograaas. «r the Equal Employment Opportunity Comet tssitm ?il reports due under the applicable fitiug iwjuirentsnfs?
i 1 Yea n No
Have you participated in any previous contracts o- tatbconSfacu: subject to ihe equaS opportunity clause'?
[ 1 Yes f ] N'o
I! yosi checked •'No" so ijucsiioa l.tvJ. above, ple;;.«r provide an cjcptonatroi!:
Page 10 of 13
SKCTtON V II - aCknowj.kdgmknts. contkact iNCOKI'OKAi iov COM fM.I ANCI-. TfiNAl.TlE.S. DISCI.OSIjRK
fhc i >:srlii-iifii; /'arty understand:: and ar.rcr-r lh.iv :
A. The cciuficafiiin:;. di'ie iusure::, and acfcnoivkdp.Mionls contained in lbi:> liDS wilt become par* of any euat::ici o; olhc* ai-icemcni bctv.-ceis lEie. Applicant arid the Oily in connection with the Matte:, whether procurement. City assistance, or other Cily action, and are material ii:di.-.-cn*cr.tx to the City's execution, of atiy euntrnct. or taking olher action with respect to the Matter, i'lie Difclosuv; Party understated:: that i; must comply with all statutes, ordinance:!, ~nd repo5tii.iu:is 0:1 which this !:I)S baioij.
13 The City's Covetarncntai Et.lncs aatl Campaign Fitiaac.::;'.; Ordinance-;. CiiyV'"---"11 1-!. 5. and may also he obtained from the City'- Boa;.! ol" Kt.hies. ?-HI N.
SediHvtcJs St Suite .500, Chicago. IL MhfclO. (512) 7-M-»66». The Disdain:•. Party must comply fully w«b the applicable ordinances.
C. If the City ilciciuiincs that any infontialiors provided in thitt EOS is- false, iu complete or inaccurate, any contract ot oilier agreement iu connection wich which it is ta.ibmitted may be rescinded or be void or voidable. and the City rrtsy put Sue any rented ies uadc: the contract or. aeiceuierJ (if on; icscaaied or void), at law. or in equity, including terminating the Disclosing Patty's participation iu the flatter andfo-i declining to allow the Disclosing Party to participate tn other tiaiisactiuav. with »hc City. Remedies at law for a false stalctncut of material fact may include itxarctratjua and an awaid to tl?c City of treble damages.
O. It is the City's policy to maUe this document available to the public on its Internet site ami/or upon request. Some or all of the information provided on this EOS and ar.y aiiacbn>cnts to this F.DS moy be taade available to the public on the Internet, i» icspnnsc to a Freedom of Information Act request, or otherwise. Ry cooipletiuf.; aad signing thitt KDS, the Disclosing Party v/niets atid se leases acy possible rights or claims which it may have against the Cily in connection with the public release of information contained in tha-hDS and also authorizes ihe Cily to verify ihe accuracy of any'infomtaoon .velitiuited in this KDS.
Ii. The infonnation provided in this BUS must be kept current. Iu the cvcoi of changes, the Disclosing party must supplement this EDS up to the lime the City takes action oo the Matter, if the Matter is a contract bcittc, handled by the City's Dcpariaicnt of PfoCureutent Services., the !>:;a-.io?iti& Paity must update this KDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-2' of the Municipal Code f imposing PERMANENT INKCK.'IIUUTY lor ccrlase specified offenses}, the ijifomiation provided hcrcia rcgardtcift eligibility innst he fcept cuiteut for n tppijcr period, as .'Lifutred by Chapter f-21 and Section 2-15^-020 of lite Municipal Code.
The Disclosisitf Party represents and warrants that:
fa;?: It of !?
• 1'nn.t <^ly^.*'rj2nhf i»f DiM.'ft»cin<; F'tirti!
iSt{>n heTJ
•.fueit or type oiiiror of yterwa ctjiatitiil
'•.'jus?:*
ilfr«:1 i» type tttltf oi pcrtori msrcujI
;:*c*. . t i>uik>. .ij^ff' I'^tate,
1 L,UH^:':'2V:^^-- N,dai. PubM
orss;r.i. s-fju h
^ ^jryP-.-Mij. St^amrsw ^ V M»^!W«««^fe»Pti£3S-ps.2Ci; (
CITY OK CHICAGO
KCONOMir wsclosuks statfaii-.nt a no aim i> \ vrr
fr'AMLUAt. KOATlONStllPS WSTM ELECTED CITY OFFlCtAi.S AND ftl'.i'AKTM&vT UKADS
Tais Appendix is in lie completed only l.ty (a) On; Applicant. a:id (?>) any legal entity v%-hicli lias a direct owucrxhip intci'cit in the Applicant e.vrccdiag 7.5 in'rcenf. It is no! ro he coii!jj5triir<: by atty lej£ii entiir which hats OQiy an indirect wwatTthip interest ir. the Applieani.
'.¦tldcr Murricipai Code Scirtroit 2-15-WJ15. the Pisclui'mg Pari)1 at!isl tJi>c!uj« M-ltcthar sach Discfosirta. Cany or any "Applicable Party" or any Spa-use or Demesne Partw thereof ciarv.ni iy has a "iamtlia! rciaticcishrp" -.¦.-iii! taty elected c% official or iSspailinexit head. A laiailial relations: exists if. as H" tin: date iliac I IDS ir-isijncd. the Disclosing Party or any "Applicable Party" ot taiy Spouse or Donicsitc Partner thcrwd'-is n&stcd u> ife* auyof, any niccrotaii. the city clerk, the city treasure? or tsty cfty decarttaent head as sptrene ordontessra partnci uras any ofthe following, vheiliur by bkjod or u&tpitoa: pareat. ch.'.W. brotlic: is s:.;::rr. «um ot uncle, niece or nephew, granctparcat. grandchild, fahcr-in-law.-, uiolfcej-iti-Usv.*, scri-ia-lav.-, dstajh^r-in-i&vc. ssepSather "Applicable Pnrty' nteaitx(l) nfi executive offiosfS ot'tlte Disclosing fatly IwJed in Section li.l.i.i-1 it"die Disclosing Party is a corporation: all parittcni of the Disctosicig pany. if Ac Disclosing I'any is .-> general partnership: all general partners and limited partners ofthe Disclosirq; Pany. if the Dj'slosrng Pany is a limited partnership: all managers. inanagin* members and members of the: Disclosing i'any, if the Disdosirts; Parry is a limited liability company; (2) all principal officers of ihe Discfottrr-s Party; and (3) nay person h.-mng more than a 7.S pnccotfiWncMhqt interest in the Disclosing Party. "T'mtcipaJ oidoaxT tnesps the prtssufent. chief operating oflftctT, execotivedacuior. chief iuKatcial officer, ircasa.'ei or secretary of a legal catiiy vt arty parson exercising, similar ruidutstity.
Docs the Disclosing Party or any "Applicable Party"' or airy Sjtousc or Domestic Partner ihtseof etinenliy have a "familial rcfauon&tp" wilh an- eteeted city official or department head"-'
[ jYcs DO No
If yes. please identify below (1 > the name ?sp,CITY Oi-'C3i;r,v,G ECONOMIC DiSCI.OSURK STATSivJtiNT AN)) A5''2--iD.Vv'f;'' APPfcNDfXi:
BUiLDING Ttsia Aftpendi* is to be rttmptelcd only by {«! the Applicant, a.nd (hi ;:ay legs! entity •.vhieh has a direct owoersrvp interc*! is the Ap{i*ir-.;r.? rxeewfisj* 7.5 perecui (:«¦; '-O'ACar*'). i: is ro be completed 'by a::v !c?vH:;vn::":" ;n Uv.- .Applicant.
). Pursuant t« Municipal Ccsde Section 2-1 5«W)I0. is tise Applicant or ;«iy Owtict identified ns a buildingcode scofflaw o? problem landlord pernsaiM to Section ?-92-4 i 6-of I he Municipal Code?
{ J Yea fXj No
i if the AftpltaHH te a Icra? enaify publicly tnaJed .ay dcehaage. i> at:y -if siccr er^iieeturof tt'ie Applicant idcat">:3id ^ a building co& scolthv <~ pmblcft! latrilcrrd p«au.i.n ro Section 2-92-11A of tSic iVuiiietpai Code?
| ] Yes | j No |X! N*w Appiicahic
i It yes to{f) ot<2J abawr, please t&plify bciovt the name ofthe per*vn or legal entity
tdcntifiexf as a taiMng code scoflls'W or pnibrrtn tetfilun! and the advlsvw of the build:;tgor Saiildings to which pertinent cods violations apply.
H U.ING OUT Tim APPENDIX B CONSTITrUTES ACKNOVVLEDtift? KJVT AND AGREEMENT THAT TBIS.APP.ENDIX Si £8 ItVCORKWRATED BV REFERENCE INTO, ANS> MADE APART OF, THE ASSOCIATED KBS, AND THAT THER,E^RESENTATION8 MADE IM THIS APPKNDIX B ARK SUBJECT TO THE CEATf^CATlON MADS (TNDRK P8KALTY OJ-PERJIJR V ON PACK 12 OF THE A58SOCIATKD KDS-
CITY OK CHICAGO ECONOMIC DISCLOSURE STAT1M F.NT AND AFFIDAVIT
SECTION r- GENERAL INFORMATION
A. Legal name ofthe Disclosing Party submitting thi-s EDS. Include d/h.-'a/ if applicable: Julie Ii. Sotui 2012 Family Trust
Check ONE of the following three boxes:
!«:diC3re whether the Disclosing Party submitting this EDS is: 5. f 1 the Applicant OR
2. |yj a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an Interest: 1136 South Wahxsh. IJ .C
OR
3. ( } a legal entity with a right of control (sec Section il.B.l.) Slate the scgal name of the entity in
which the Disclosing Party holds a right of control: „
ft. Business address of the Disclosing I'arty. ifel N. nark St Suite 4Wtn
Chsuugp. 11. 60601
Telephone: 312-636-6937 Fax: kmail: mkmd»!%2Ci#taes-!i>r.ci\m
Nome of contact person: Rntamfo ft. Acosta
Federal Employer identification No. (ifyou have one);
Brief description of contract, transaction, or other undertaking (referred lo below as the "Matter" ) to which this EDS pertains. (Include project number and location of property, if applicable):
PbiouxJ Development fur 1136-40 S. \Vab*sh/26 IL Roosevelt RA (
( i. Which City agency or department is requesting this EOS? DPD
If the Matter is a contract being handled by the City's Department ol" Procurement Services, please complete the following:
Specification » and Contract fl
Page 1 ol 13
SVXTiON H -- DLSCLOSUKIi- OF OWNKRSHiP iNTLR LS TS
A. NATURE OF THE DISCLOSING I'AK
' Inthialc the nature of the DiS'-sasini'.
i j Person
I j Public iy registered business cosp
1 I Prsvatcly hciti. busiaiiS eorptfrtition
i ; Side propriclorsbip
j i ('Icnora! partnership
{ 1 Limited pftftrutrsitip
K'l t rust
Pam¦:
[] Limited li.'sljiiity company I j Limited liability pniifu'ishin
[ ) Joiv.l vcHUil'C
[ 1 Noi- for-profit corporation
(is the not-for-profi: wryott'.tion nisn a .501(c)<3))V
{ t Ve-; { j NV
[ J Other (pk-.asc specify)
1'. l-'or legal entities, the state (or foreign coitnuy) of hicoqioraLion or organization, if applicable: tlutOiS
3. 1'or legal entities not organized in the State of Illinois: Mas the organization registered to do business in the State of Illinois as ;» foreign entity?
| [ Yes [ 1 N'o |>3 NVA
li. IF THL DISCLOSING PARTY IS A LEGAL ENTITY:
>. List below ihe full names and titles of flit executive officers and all dircciors ortbc entity. NOTE: For not-for-profit corporations, also iist below alt members, ifany. whkb are legal entities, tl there arc; «o such members, write "no members." l-'or trusts, estates or osier sintihir entities, list below the legal titlelioklcffs).
'f the cotJtv is it general partnership, limited partnership, limited liability eotnpaay. limited liability partnership or joint venture, list bdow the name and title of cscb general partner, managing member, mmutggr or any other person or entity Owl controls the day-to-day ntantigeutci.il or the Disclosing Party NOTE: Each legal entity fisted below must submit an EDS o» its own behalf.
Name Tide
Tbc'iiea M. Swill Tsifclee
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (ineluding ownership) in excess of 7,5% ofthe Disclosing Party. Examples of sucb att interest include shares ki a corporation, partnership interest in a partnership or joint venture.
interest of a member or manager 5 ft a limited liability company, or interest ol a bencticiaryot a 'rest, estate or other similar e.ntitv Ifnonc. state "Nunc." NOTK: Pursuant io Seeti.»a .1-15-1-U. 50 oi the Municipal Code of Chicago {"Municipal Code"), the City may requite any sunn additional iulurtoation !£«.•-; :::iy applicant which ss reason;: h I y ifiteftded to achieve f>;l! discioSKrc.
t '• os: n es s A dd rv;?:s
Percentage interest in utc Disclosing Party
¦ i-.i-T..Tf. N? Six«, i/.I :< L7:lik Si ^»Ss4Vi:i). (.^icrjjvv ft. 60r-ii;
SECTION HI - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as. defined t- CUotm-t 2-l5» ofthe Municipal Code, with any City elected official in the I?, months before the date this EDS is signed?
[.! Y«. bd No
If yes, please identify beiyw the namc(s) of such Ci:y elceied officialise! aud deseiibe sucfe relationshspfs):
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consoliant and any other person or entity whom (be I >isi.lt isinp Party bus reumted or expects tn retain in connection with the Matter, as well as the nature of the relationship, and die lota! amount of die fees paid or estimated to be paid. The Disclosing P-r'.y is nut required to disease employees who tire paid solely through the Disclosing Party's regular payroll
"Lobbyist" means any person or entity who undertakes to influence any legislative or admimstralrve :eetion on behalf of any person or entity other than: (l}a wot-for-profii entity, on an unpaid basts. or{?.} himself. "Lobbyist" also means any person or eulity any part of w hose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure ts required voider this Section, the Disclosing Party musl either asli the City whether disclosure is required or make uV disclosure.
Ptific .> of 13
Name (indicate wftclbet Business Relationship to Disc Win.;'. Pany Kw-s i.ind:e»Cc whether
retained or anticipated Address (subcontractor, attorney, paid m-estimated.} NO I L:
u> be r<:i:iir.cd) tnhbyist. etc.) •"hourly rule" or "l.h.(i.v is
."oi .v; accopi:d'le rc-tpons-r.
; Add irreois if necessary)
;<] Check here if the Disclosing Party tuts not retained, nor expects to retain, any such persons oj entities. SECTION V - CERTIFICATIONS
COl)RT«ORDF.ftRD CHILD SUPPORT COMPLIANCE
Under Munkipat Code Section 2*92-415. substantial owner* of business entities thus coMtmei >vh.h the City must remain in compliance with their child support obligations throughout (he con tract's term.
Has any person who directly or indirectly owns ;0% or moir. ofthe Disclosing Party been dec-las eu in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
—[) Yes'— Jjjjfto ( ) No persotrdiicctly'oritrdtrgciry-owns-J0% or-rnor-e-of-tlKf-
Disclosing Party.
If ""Yes," has the person entered into a court-approved; agreement for payment of all support owed and is the person i« compliance with that agreement?
11 Yes UNO
FURTHER CERTIFICATIONS
1, Pwtsuartt to Municipal Code Chapter 1 -2.L Aniclc i ("Article f'Kwhich the Applicant should consult for defined terms (e.g., "doing business") ao
Page 4 of S3
The i>ir?i=tfiS.-IiTi£; Party and. it UIC Discloso:;,; Party is a leg*' canty, ail <.'¦* those tX-TSuli:- or identified -n Section If.li. I. of this fiDS.
:i. are not presently debarred, suspended, pioji-rjsed for debarment, declined oicii^dtdc or volunMr'Oy excluded from any iruntttctiotK by any federal. :-'aie o; local «nit of governnicif.:
i>. have not. ;v:thiv a five-year oeriod preceding the date <>* the. .'-.OS. been convicted o' a cvofiiri.-j! oflVn.sc . adjudged guilty, or had a civil judgment rendered agamst them in counsel ion with: obtaining, attempting to obtain, or perform tng a pubhc (federal, s!::'c or local) iraosiicitoo • contract under a public transaction: a violalioo of federal or ssale amis;us; ssaiiiies; fraud: embezzlement: thefl; lottery; bribery: falsification or destruction of records: making false statements: or receiving stolen property;
c. axe not presently indicted for. or criminally or civilly eharj'ed by, ^ governmental entity {federal, state or local! wilh commiiiinji any of die offenses sci forth »n clause R^.b. of this .Section V;
have not, within a five-year period preceding the date of this F.DS. had one or more public transactions (federal, stale or local) terminated for cau^e oj defauit. and
have not. within a five-year period preceding she dale of this FDS, bee: convicted, a-djudged guilty, o? found iiablc in a civil proccedim:;, or in any criminal or civil action, including actions, concerning environmental violations, instituted by Utc City o? by the federal government, any state, or any other unit of local government.
The certifications in subparts .>. 4 and S concern:
the Disclosing Party:
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party 151 connection with the Matter, including but not limited io ail persons or legal entities disclosed under Section I V, "'Disclosure of Subcontractors and Other Retained Panics" !;
* any "Affiliated llnttiy" (meaning a person or entity that, directly or iocUrtieiiy: controls the Disclosing Party, is controlled by the Disclosing fatly, or is, with the Disclosing Pony, under common control of another person or entity. indicia of control include, without imilalrtm: mterlockiog management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organisation of a business entity folio w;nt- the roclifiibiliiy of a business entity to do business with federal or state or local government, including lite City, using substantially the. same utanayement, ownership, or principals as the ineligible entity): with respect to Contractors, the term A ffiluiied Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by ii. or, with the Contractor, is under common control of another person or entity:
• any responsible official of the Oii'chtidng Party, any Contractor Of any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated F.rmiy. acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Patty, any Contractor or any A (filiated i-ntily (collectively "Agents">.
I'ac;e 5 of 1.5
Neither the Disclosing i'anv. oorany Contractor, nor aav Aittbaied ;-n;ey t!i cither the L>j:>c!¦ »^-. i'zn-; or any Contractor sior ::tiy Agents have, dunng, the ft v.: years before the da:e th>s I-! is sis, nee. oi. w;. Contractor, aa. Aitiiialed Entity, or a*: Affiliated Knlily of a f omiactor during the 1 ive ye;:::, before the date of such Contractor's or A ffiliated lintity"s ceviraci or engagement tn connection -.vhh fr.r
Mti-.ter:
s bribed or attempted to bribe, or beer, convicted or adjudged gu'thy of bribery or at««;?:i|«li»«t;. io bribe, a public officer or employee ofthe City, the Stave of ItHuoi^, or any aueney of the iedcril government or of any stale or local ;.is, agreed or colluded with olher bidders or prospective bidders, or been a pany to any such agreement, or been convicted or adjudged y.oiity of agreement oi collusion among bidders or prospective bidders, in restraint of freedom of eronperition by agrceru'Dt lo bid a fixed price or otherwise: or
made an admission of such conduct described in a. or h. ;d«-violated the provisions of Municipal Code Seel too 2-9'i'dtO (Living Wage Ordinance).
Neither the Disclosing Party. Affiliated Entity or Contractor, or any of their employees, officid.y. agents or partners, is barred from contracting with any unit of state or local government as a result of aif&ginit in or bsinjj convicted of {I) bid-rigging m violation of 720 ILCS 5/33li-3: (2) bid.totadn.fi in violation of 720 ILCS 5/33E-4; or (3) any stro iTar offense ol" any slate or ofthe United States ot America that contains the stone elements as ihe offense of btd-ri&girtc; or bid-rotating.
Neither (he Disclosing Party nor any Affiliated Fntiiy is listed on any of the following lists maintained by the Office of Foreign Assess Control of t?ie U.S. Department of the 'treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors.; 'be Specially Designated Nationals List, the Denied Persons List, the Unverified List, the I-nltty List and ihe Debarred List.
b. The Disclosing Party understands and shall comply with ihe applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Govern mental fjlhies) ofthe • Municipal Code.
7. If the Disclosing Party is unable to certify to any ofthe above statement.? in this Par* Ii (further Certifications), the Disclosing Party must explain belov
Page 6 ol" i
:Aihc loners "NA." tii:; woid ".\\mor no rc.si>i!!*;;e :!!>):•.-.;?s on >!.;: !:ti::s ::>-:hv ii -.i-ill h.- condiv.ivv.-l v presumed ih::! the Disclosing Party cerlified •<> the above suttemcms.
•S. '!'¦« ih-,- f>i.:-'. of ihe Dis.cl;isi;ir Party's v.imv.-:.cc!ge a!''.e; ;\v.t;:o!,.:ih!e inquiry, the loihrvvir.g is complete list of all current employees of the Disposing Party who were, a! any lime during the i":-nionth period preceding the execuHon daie of this F.DS. employee, m elected or uppcmitev- ofiieeil. of the Ci:y of Chicago (if uooe, indicate with "N-'A" or "stone").
None .
*». To the best of the Disclosing Paries knowledge after reasonable inquiry, the folVituntsg is a complete list of all gifts that the Disclosing Parly ha.-, given or caused to be givea, at any time doting 'the 12-month period preceding die execution date of Ibis KDS, to an employee, or elected or appointed official, ofthe City of Chicago, h'or purposes of this statement, a "'gift'' does not iaclu.de ; (i) anything mode- genera Fly available to City employees or to the general public, oi (si) food or drink provided tn tb? course of official City business and having a rciio't v;dnc of less than S2 (if none, indicate with "NfA* or "none"). As to any gifi listed below, please also iist the name of die City recipient.
Wore
C. CKRTTFrCATION Of- STATUS AS FINANCIAL INSTITUTION
L The Disclosing Party certifies thai the Okirlosing Party [ ] is 1X1 is not
a "financial institution* as defined in Section 2-S2-d55(b) ofthe Municipal Code.
2 If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and wifi not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affiliates is. and none of litem will become, a prcdaturv lender as defined io Chapter 2-32 of die Municipal Code. Wc understand thai becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofi.be privilege of doing business with the City."
If the Disclosing Parly is unable to make this pledge because it or any of its affiliates (as defined io Section 2-32-455
Page 7 of 13
!J ihe tellers "NA," me tvord "None." or no icspon.-cr appears on the b"es above ¦' v/ii! r-e conclusively presumed thai Ihe Disclosing Party ccfiitled lo die above statements.
D. CERTIFICATION RliCARDIN.0 I NT)-REST IN CITY HUSINESS
Any words or terms that arc defined in Chapter 2-15G of Ihe Municipal Code have the same meanings when used in ;%is Pan D.
in fite.it (dance with Section 2-1 So- > 1(V ol' the Municipal Code: Docs any official or employee of the Cily have is financial interest in his or her ov/n name or in the name of any other person or entity tn the Malica-?
1J Yes k) No
NOTIZ: Ifyou checked "Yes" to Jtcro D. I... proceed to Hems D-2- and D.3. Ifyou cheeked "Vo"- so lie its D.l „ proceed to Part Ii.
Unless sold pursuant to a process of compel it ive bidding, or otherwise permitted, no City eitcted official or employe* shall have a financial interest io bis or her own nsme or in the name of any other person or entity in the purchase of any property that (t) buto>H;s 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 the Matter involve a City Property Sale'.'
[ | Yes | ) No
Ifyou checked "Yes" to Ue«t DX. provide the names and business addresses of the City officials or cntployce& having such interest and identify the nature of such interest:
Nome Business Address Nature of Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION .REGARDING SLAVERY BR. A BUSINESS
Please check either t. or 2. below. If the Disclosing Party checks 2 (he Disclosing, Party must disclose below or in an attachment to this EDS alt information required by paragraph 2. Failure to
Past JI of 13
cumplv with these di.velo.-;me requirements may make any eoiv.tae! entered into v.-oh ihe t.oy m connection v. iih .lie Malic:' votdidde b\ the City
X i. The Disciosir.i* Party verifier, uiat the Disclosing i';.-rfy h.-% te^idicd any and nil record* o: ibe Di.sriosun: Pany and anv and ali prcdeccfe'ot ecu ides rcrardntt: tecurds of investments or pro!Us Worn slavery or slaveholder insurance policies dialog the slavery era iii'cUuiuig insurance policies issued to slaveholders that provided cnverap.e for dsnugc to or injury or death of their slavey, yml ihe Disclosing Parly hjss found no such records.
2. The Disclosing Partv verifies that, as a result orconJueimp the search ir.' step t above. Ihe DisctoMiig Party has found records of investments or profits I'rom slavery or sbvcholdet insurance policies. The Disclosing Pany verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those tccon'.*:
SECTION VI - CERTIFICATIONS KOft FEDERALLY FUNDED MATTKRS
NOTE: If the Matter te federally funded, complete ibis Section Vi. If the Matter 5s not federally funded, proceed to Section Vfl. For purposes of this Section V!, to* credits, allocated by the City and proceeds of debt obligations ofthe City aie not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed thai the Disclosing Party mean.? that NO persons ot entities registered under the Lobbying Disclosure Acl of IW5 have made lobbying: contacts on behalf of the Disclosing Party with respect lo the Matter.,1
2. The Disclosing Parly has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law. a member of Congress, an officer or employee of Congress, or an employee of a membtrr of Congress, in connection vim the award of any federally funded tontrtsci, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, commue, renew. amend, or modify any federally funded contract, grant, loan, or euopeiativt agreement.
Page «J of 13
3. The Di-ictusing Party will submit an updated certification at (he end uf each oki-dat quarter in which tliers oeewrs .'my event that materially affects the scot'-scy of the staiarrtojiis and iri'brmriucn tbnii in paragraph** A. 1. and A,2. abu*.-.-
'1. The Disclosing Parly certifies that either: (•> it. is not ;:rt c-rtinuii::-4.n?ii ^escribed iu section 501 (t°){d) of the Internal Revenue Code uf ! '?.*>(>: or (ii',i it is an ore.ani?*!lion described iu see: ion 501(c)(4) of the internal Revenue Code of 1986 but has not engaged and will sr>i engage t» ''! .obrvytm-Activities^.
S. U'tSte Disclosing Pany is •he Applicant, ihe Disclosing Pany roust obtain certifications equal tm form and substance to para^mphi: A.l. through AA above from all subcontractor*- before it -iwaids any subcontract and the Disclosing P;*rty must maintain all such subcontractors' certifications for die duiaiioa of the Matter and must make such certifies do is;; promptly available to the City up©:: request.
ii. CERTIFICATION REGARDING* EQUAL l:*-IPLOYMFNn" OPPORTUNITY
If the Matter is federally funded, fedo:d regulations require the Applicant and aJi proposed subcontractors to submit the foUo'.vinw. information wnh their bid* or in writing at Ihe outset of negotiations:
is the Disclosing Party the Applicant?
[ j Yes { j No
if "Yes." answer ifae ihr-jc uoessiions below:
Have you developed and do you have on file alTimuuive action programs pursuant to applicable federal regulations? (See 41 CFR Pan 60-2.)
I J Yes I J No
Have you filed with the Joint Reporting Committee, the Director of she Cilice of FetJertd Contract Compliance Programs, or the Equal tSmploytfieut Opportunity Commission all report;; doe under the applicable filing requirements?
(1 Yes {] No
Have you participated in any previous ¦•oni-acts or subcontracts subject to the ecmaJ opportunity clause?
Y}Vcs I JNo
Ifyou checked uNo" to question J. or 2. above, please provide an explanation:
SECTION VII- ACKNOWLEDGEKNTS. CONTRACT INCORPORATION-1. COMPl.fANCK. PENAL.'!-!ES. DiSCLOSUKL
flic DiscJosint". Parly w«sj«rivt-Jirtfand screes thai:
A. Tin: certificnttonsdisclosutcs. and neknowlodgments contained in this EDS v.ili become pari oi any contract or other aiyeuoiein between the Applicant and the City iu eouneutioii with tite Mallet, whether oroecfcniem. City assistauc-- or other ("sty action, -md are material inducements to the City's cxect:t;i»i rii'anv contract or tat: in s- other action with rcsocet to the Mailer. The Disctosmci Party under*;! arris that it must comply with all statutes, ordinances, and "regulations on which thin EDS i.s boicd.
si. The City's Governmental Ethics-and Campaign Financm-.; Ordinances. Chapters 2-1*6 and ~>.-\(A of the Municipal Code, impose certain duties and obligniida.*- on persons or entities seeking Ciiy cousracsx work, business, or transactions. The full test of these ordinances and a traina-i-.: oroj'.rain is available on line as. w\vw.ciIyofehic.ago.orgf\jihtcs. and may also be obtained from ihe City'.s Board of Ethics, 740 N.
Sedgwick St Suite SO0, Chicago, IL 606i0. {ji i 1) 7If the City determines thai any information provided i» ibis EDS is false, incomplete or inaccurate, any contract or other agreement :«i connection with which it is submitted may he rescinded or be void or voidable, and the Cily may pursue any remedies under the contract or ayreemei.a (if not rescinded or void), ;it law, or in equity, including tetmmating the Disclo-W'S. Party's participation io the Matter and/or declining to allow the Disclosing Pany to pai»ieipa.;e in other .'rpn.sactuiftx with the City. Remedies a: law for a false statement of material fact may include Incarceration and im award to the-City of treble dtunages-.
It is die City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on ibis EDS and any attachments to this EDS may be made available to the public on ihe Internet, in response io a Freedom of Information Act request, or otherwise. By completing and signing this £DS, the Disclosing Patty waives and releases any possible rothis or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes ihe City to verify the accuracy of any information .submitted in this EDS.
U. The information provided in this EDS must be. kept current. In the event of chauyef., the Disclosing Party must supplement this EDS up to the time the Cily tafces action on the Mailer, I f ihe Mattel is a contract being handled by the City's DcpaMntent of Pro-rusetnem Scrvtees, the Disclosing Parly must update this EDS as the contract requires. NOTK: With respect tn Matters subject to Article i of Chapter 1-23 of the Municipal Code (imposing I'EUMA.NK.Vi* INELIGIBILITY for certain specified offenses), the information provided herein rcg.ardini» eligibility must be kept current foi a temper period, as required by Chapter 1 -25 and Section 2-i 54-020 of the Municipal Code,
t he Disclosing Party represents and warrant?! that:
Page ' / of ! .1
>¦'.). Yhc Disclosing. P;>r:y i.-; not delinquent m '.he- payment cf any in:-, adssimisicf.;-:.! hy the : iiim.;:.-.
D>-p;»ri.meoi of Revenue, nor sore the t>i*si:to«s>*«:-i Party or its AiTihaled l-nthics delinquent in pa yi any
t'ii'ic. fee. inx or other ch'-rp.e owed the- '.;?y. this ^u.-:t bat ;s ma hrr.ilcd io. iii ater :v-:±-z:-:„.
Sfwtr cha.rjje.-5 , license fees, parking ticket:-., propci-tv la-ics co sai::.s mw*
F.2 If the Disclosing Party is the Applicant the Dtsrlosbj; Party and its Affiliated Entities will not use. nor penhit iheii suheoniraetors «o use. any facility lifted by lite U.S. it.I'.A. on die federal Excluded Panics List System ("EPLS") maintained by the U. S. General SV.-viee.? Ariminrsiratior.
F.j Ir the Disclosing Party is the Applicant, the Disclosing i':*ny will ohtnia from a-iy contittclOtf/subcontTaceors uirecS or to be hired sit connection wuh the Matter certifications equal w rbrnt and substance to those in F.I. and IY2. above .-tod will not. without etc prior u'rirten consent of the City, use any such contractor/subcontractor that does no! provide such ccntticasious o; that the Disclosing Puny has reason to believe has not provided or intoi provide tuiiafo! ccriificatii>?.is.
NOTF.: If the Disclosing Parly caor.ot certify as to a»y of the items fe F.l i.2. ot F.J. above, an explanatory ststefttent must be attached to this EDS.
CKRTIFICATION
Under penally of perjury, the person sigjiiag below: f 11 warroitts thai he/she is au-norized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Pany. and (?.) warrants that all certifications, and statement-; contained ir. this EDS and Appeitdi-t A (if applicable) are in.ic, accurate and complete as ofthe date furnished to the City
Mist- KaM?Jft|2r-auh-Tiusti (Print or type name of Disclosing Parly 1
ny: r;;"-;;^'.^
(SigtVhcre)
fhomg- M. Saiit
\ Print or type name of person signing)
fuses
(Prim, or type tide of person signing)
Signed and sworn to before me on (date) Pj'tL. 'J
m jc&ak _ County, Minus (state).
. [ / / si?.-}*"
I , i . j .-£/< ~r.~-~ t , (
Commission expires:
'-"ns--* " --Vwc; Set: - a«. .
Oi i v of chscaco
ECONOMIC DISCLOSURE STAYtYJvit.vYf AND AEKIDAVl'I A.PP ENH: X A
FAMILIAL RELA i iO.NSMIPS WITH ELECTED CITY OKElCtAI-S AND DEPAR IMEKf HEADS
This Appendix is to he completed only hy (a) the Applicant, and Irr^ai entity which has a direct ownership interest in tht Applicant exceeding 7.5 percent It is not to in- competed by any legal ettrifj vihich has only an indrrrrf ownership interest in thi- Aptiileae:.
Under Municipal Code Section 2-1 $4-015. the Disclosing Patty must disclose whclhtn such Disclosing Party or jsity "Applicable Party" or any Spouse or Domestic Partner tliereoCcurrently has a "Tanuhal relationship" with any elected city ofTida! or department head. A "familial relationship" exists if, :ss of the date Ibis EDS ;s signed, the Disclosing Parly or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to lite mfiyo.\ a»»y alderman, the city clerk, the city treasurer or any city department head us spouse ur domestic partner or as any of the following, whether by blood or adoption: parcut child, pother uj sisser. aunt or eac'e, niece or nephews grandparent, grandchild, father-in-law, tuoihet-in-lavv. son-in-law. daufchter-in-lavv, stepfather oi s'icpmotlrer, stepson or slcpdauidtter, stepbrother or stepsister ot half-brother or half-si&er.
"ApphcaMc Patty" means (I) all executive officers ofthe Dtsdosiiu: Party listed in Sccdca ILB.i .a , if the TVis,cicsins Party is a coqporaTion; nil partners ofthe Disclosing Party, if the DiscJosiiig, Party is n general piiitnenihip; all general partners and limited partners of the Disclosing Party, if the Disclosing Party ts a limited partnership; all Managers, managingmetubess and members of Ihe Disclosing Party, tf the Disclosing Paity is a limned liability company; (2} all principal office™ of the Disclosing Parly, and (S) any person having tnoie than a 7.5 percent ownership interest in the Disclosing Petty. "Principal officers" means the president, chief operating officer, executive director, dtief financial officer, trcaancr or stscfesary of a legal entity or any person exercising similar authority,
Docs the Disclosing Pany or any "Applicable Pany" or any Spouse or Dumcstb Partner thereof currently have a "familial ivtiuionship*7 with an elected oity official or department head?
\ JYes IX! N°
If yes. please identify below (1) the name and title of such person, (2) the itame ofthe legal entity lo which such person is connected; O) the name and title oftite dotted city official ot dcparfo-icnr head to whom such person las a familial relational! ip> a«d (4) the precise nature of Koch familial relationship.
Patsc 13 of 13
TV Or'OliCAGO ECONOMIC: DISCLOSURE STATEMENT AND AFHuAVH
BUILDING COBK SCOFF? .AW/PRC HJUeV, LANDLORD CE RTil1" iC A TIG:'•
This Appeodnt ss Jo be completed only by (a) ihe AppitesnL and (fa) any legal e::ioV -vhieb lias a direct ownership interest in -be- Applicant cseeedtag IS pcreent ['an "Gv/ser**).
r£ is :jos fo be co^.pSeflcd :'y r.ny E^-.d en ft'; which only c-i Sodireef ovrr.er-'-;p Ssi^r-reT is the Applicant.
Pursuant lo Municipal Code Sec! ion 2-1 54-010. is, tin: Applicant or any Chv-er tdeniiiied as a
i ]Ycs i'Xs No
If (he Applicant is a legal cttthy publicly traded on any exchange. Is any officer or diwctwor she Applicant identified iss 3 building vc2-l 1G of the Municipal Code?
| JYes i ] No fXJNoi Applicable
.¦>. ff yes to H} i?r (2> above, please tdesttry below the tuuwe ofthe person or lc«al entity
identified 04 3 bail
FILLING OUT TUBS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT T3AT TI5IS APPENDIX S IS INCORPORATED 3Y REFERENCE WVQ, Afc'S MADE A PART OF. THE ASSOCIATED EDS* AND THAT THE REPRESENTATIONS MADE EN THIS APPENDIX B ARE SUBJECT TO THE CERTIF1CATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 Of TO: ASSOCIATED EDS.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT A.VD AFFIDAVIT
SECTION I — GENER AI. iNFORM A 110N
A. Legal name of the Disclosing Parly submitting ihis EDS. Include d/'b/n/ if applicable: CA Kcswfcraia! 1136 S. Wii&wh. LLC
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS isr
[ J the Applicant
OR
l>3 a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: 1136 &»mh Wahusk i.i.c
OR * '
3. 1 1 a legal entity with a right of control (see Section ii.B.L) State the. legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: u,i N.Cfarfc Sl. Suite49ds>
Chicago. JL^JiO!
C. Telephone: 3t2.nJ6.693 " p2X:
D. Name of contact person: RnLimlo It. Acosta
F. Federal Employer Identification No. (ifyou have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development for I1J6-40S. WabwSi/26 E. Roosevelt fid.
G. Which City agency or department, is requesting this BOS? JDPD_
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following,:
Specification /A and Contract ii
Page 1 oi" 13
SRC'HON It - nSSCl.OSUKH CM' OWNKRS'ltli' INTHRfcSTS
A. NATURE OK'HIE DISCLOSING j'AKTY
[vi !.ir:;i!ed liability eOr;ip:i:iy i j Limited liability partnership [ ] Jen:! vtinfiire | | Not-for-profit corpomiou tit. toe ::;U-rt)!-p:ciiu corpoiiiiKiti a!«> u S0l{c)O)t?
$. jn.orcait the nature oT ihe Dkcla.-diij; Pany:
I j Pcnwui [[1 Publicly rcgLsieicd harness corputxHian i
ft Priwfcicly halt! bsisincss corporal iw» L
[ | Soi<; proprietorship |
[ 1 Ve* [ J No
i J Oilier (pit::!*:: specify)
f 1 General 5*if!:i'/rship ti
{ \ Limited piirtite-rshrp
J j Trust i
Z. For legal ciitiiie:;, the stttic tor foreign cownuy) of ineoipocation or orgoo.izfl*iu;i. ifspplicablc:
3. Kor legal eTiltti'.-s sioi organized in tin- State of Illinois: lias the csgr-.r.b-ttioii registered to do businf?w in the State of llhnnis a forei^ys entity"?
[ ! N/A
B. IF TUB DISCLOSINGi PARTY IS A LEGAL ENTITY;
L List bchnv iks fed! names and titles a?iii es-ectiiivt aflleeis and all rffroctors of tfic ««:•(>•. NOTE: For no!-for-profit coiyoratinns, also list below all i:it;:r.h«s. ifany. which arc legal entities, tf there arc no such members, write "no members.* for trusts,, estates or other simitar entities. list below the le(;r,J tideoolder(s).
if the entity is a genera: partnership, limiiet! partnership, Uini'et* liability company, iuattett liability partnership ot joint ventttre. list below the name nttd title of each i?cn«Name Title
CAMntx^t.lM' „_ Ntat^er
2. Phase provide the following information eoneentiag each person or entity ha vine, a direct o* indirect bsneflci.il interest fbdudinj'. ownership} in excess of 7.5% of the Dvel«$iny. Puny. Bxaxtplcs of suchinterest include :;!ian-s in ;i corporation, nariji£r.fhjp in teres! in a partnership or joint vesture.
imcfcst oi a tncinbc; or manager in n iiotitr;d liabslil-; company, cr ir.Ktrsst of ••> beitefseisry cf a ttusl. Iu or o:: '.? I VJ-0"t'! :-!'%•!;•
Municipal Code of Chicago (~*vlunicipai Code"). the City itsay t'. uu-.n: any such .jdd'Honai in forty;rttioc from aoy applicant winch \r- rr.aioriaolv itV>c!i%.'vd lo .-;c!:::.vr fnir cii.tcior.tti ::.
Naiae P.osirccss Adtirc.:::. Prrccntasc !ii5.CiCi;i in l!:-.'
UiiCl-,ysii!;5 Party
C'A KcsitiaBi&l. I J,'- 161 .\ Cfeil St Sims >'V1*'J. ( "mcjyy., i.' .ftiJW)!
SECTION lit - BUSINESS RELATIONSHIPS Wl I'll CITY KI.K
Has. the OisctostPs; Party had ?. "iusiasss rehtjoosijivS" -itf tk-fiaed ui Chapter of tite Muoicipai Code, with any City elected offkiat in I J Yes fjti;
fi'vL-i, please identify bclow ttie ttarnefs} of.-:uch City ciccied offteinlfs) and describe such rdstionshtpte)-
SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER flKTAINKU PART IKS
The Dr-vsjioKjo/T Ptlfly IllUSl disclose trie mum1 and iiiuctnc^s .nfrjress of C3clt subcontractor, attorney, lobbyist. xccouitlSRi, consultant ami any other person or entity tvhoia the 1)kk:Icisi:i"Loiihyi::'" jnc'ins any person oj entity who tui:*cnaktf!< to influence ooy legislative or adratnistriltvf action on behalf of any pcitton or eni»ty other than: (l)a ftoi-f©r-|>iofst entity, or. an unpaid iwsis. or {2> himself -Lobbyist'* alio mean* any pcrsotj or cnuty any pert of vi-hosc duties :-s co employee of another includes undertaking to irtfltictvcc any legislative ct adsriiiiistrsiivt: action.
U*the Disclosing Party h; itr»c.enain whether a
Paired" 13
Name {indicate whether iJusir.rs? RcLttirmrtlitp ¦<> Itacfcting Pan* I V:::; 'indicate he:;:-:-:
wnioctS Vi anticipated Address ijatbcotvirttCWf. alionu-w. p:¦<>¦ oe retained) tohbyiyi. wc.) ';k:c^v ra'.c" or••t.b.cV is
rint an ac-Cf<>ia-h:i rt:::pi-i:i;t.
(Add! s!n:t:ts if accessary,;
Check here if the Disclosing Party has inn rctaritsd, norcxpecu; to i eta in. soy Sitzb poison; w eaitilaii SUCTION V -CliRTtPlCATiONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
UGder Municipal Code Section 2-02-415. ::ub:;t:>.mial owntm of bu.«>naa: entities that contract v/tir; the City must remain in compliance with their child support obligation:: tUnaogfcout the contract's tern*.
Has arty person who directly oi indirectly o**HS 10% or moiv ofth-5 Disclosh:;; Patty fcacr. ctccL*rco iu a/rcsuage nst any child support oattgations hy any Mliaosc court of competent jumdfeiron?
— lx|-No tJi^crsti»rdii*ffitl7TyrTftT[|!r^^
Disdur; ho; Pany.
If "Yes," tos the person entered into a courl-appiovcd a&rccnre-iH lor payment a fall support owed tint ii; the person in coinpliajtec tv-iftjj Jha; agreeiejent?
(JYes \}tio
FUUTHHR CERTIFICATIONS
I. Pu«a.s,iju to Municipal Code Chapter f-2J5. Article I (-Ankle- P'K-.vhicb the- Appltca.«tt should <:or,.sult fordcrfbicd "turns (c,^., "dottits, busi itM.-f'j atttj legal recutreraenin), if the Oisciosiq- I'.-riy submitting tfii:; EDS b> the Applicant and is rtoinr, business with lac Ci?y. theft the nb*2nei»ily kudu-tcd or chr.-^ed with, or has adm itted guittof. or has ever been coavieted of, or placed ttittlci sajwrn-iaton for. any criminal offirn.se involving actual, attempted-, ©i conspiracy to corarajl bribery. theft Fraud, forgery, perjury, dishonesty or deceit agaiost tin officer or employee of the City or any sister sgency; and (ii) tru-Applicant tirtdctstands aad acknowledges that compliance with Article E is a continuing rc-auireihtxt for doing business wiiii the City. NOTE: If Article ! applies to the Applicant, the permanent coaiplbftcc li'mcftaotc in Article i supersedes some five-y^ar eomplitut.ee timeframes in certifications 2 a"i! 5 bciuw.
Pogt4of Vi
-• f>i>.::!nsrf!j. :':i::y :ui:!k::' :f>c Di.ie'o::!.".!:, i'r.rjy v. ,1 iey;ii cutity. :tii of .-boSe p-vfS'.n:.* :ii entities
itieuiifiod in Secli©:: !?.;!.;. of H!JS:
Tire not presently dc:h:in\-:d. siiSpCfHted, p'npor-sd for dcbatvitenl. rltvj'arc-i ine'irib!* or voierr.ii :!v excluded fro- any uair-jau-.tto-is. by any federal, slate o; local unit <:•;' jtovcmmcivi.
have not, within a five-year period preceding the dale of litis 1-!>S. been cou victc-d of a ctinnna? offense, adjudged rjuilly. or had a civil j;;.Ii;:;ic:it fciitfe.'ci against them iu co:i:K:ei»>ia with; ofciaimr.v attempt tag to obtain, or pcrformiDj. a poVdic (federal,, state or local) tn;r\<;.-icuori or conttact undirr » piiblic transaction; a violation of federal or «z.Uc aiibttUA.; sa:i:;itcs; frau'i. efkibnatlcntent; theft: forgery; bribery: falsifieation or iHvsiriieuoj! of :ecor propcrtv:
arc not pjesenily indiaed foi. or ctsmsonlly or civilly chat god by. a governmental catity {federal, state or lotah with comfi'iiuiuy, any of the offenses :.et f<«th in clatii'e ft.rt.b. of this Section V,
it. have no;, within a Jivc-ycar period preceding she date of this MIXS, had one otr ir.to:c puhlir transactions (fadcral, state or local 1 term :r.n;ed for cau&e or Jefault; and
c. have not. wit his a five-year period preceding the date of ;his BUS, fct*c*» convicted. iiditidtied fptilty, or ioetid liable, in :i civil proceeding, or in any criminal u» civil actioa. including action:: coftccmiaiir, env:rcn;rvten!:tl violations, instituted by *he City or hy the federal fitovcrninenl, ant* slate, or any oihe; unii of local government.
a. The. certifications n: subparts *>, 4 arid 5 concern:
" ihe Disclosing Paily;
- any "Coatractor" (meaning any contractor or subeootiacto: oscrf by the Disclaim; Parly tn connection with the Matter, including but noi 'limited to ah nerpons or legal entities disclosed undci Section IV, -Disclosure of Suhcontiacton; ojtd Oliver KctasncJ Panics");
any "Affiliated Entity" (titt-aniis;; a person or entity diat, directly or indirectly, controls the Dkehtsing Pany. is coati oiled by the Disclosing Patty, or is, with the Dwc losing Party, tittdet common oontiol of another permit oi entity. Indicis of control include. veithot!? liiuiiaiKi::; iaicfloekiag nianar>,eiricrjt or ownership; identity ofiotc/csts among family tncuibeiii, -faired facilities and equipment; common use of employees; or organr/ation of a business entity follow^ the ineligibility of a busirieam entity to do busine-a: with federal or state ui local government. sndsi-Jin-i; the City, using substantially the sotc nHiaagciiien:. ownership, or principals ns the ineligible entity); with respect io Contractors, the terro Affiliated KntUy means a pcr-am or entity that directly or indirectly controls the Con tractor, is coniicriied byii. or. with the Contractor, is under common eoarrol of Another person or entity;
any responsible olTictal ofthe- IJiscrottng Party, any Contractor or any Affiliated Entity or any other official, agent or employee of lrtt: Disclosing Patty, -jay Contractor or any A IVihatcd Eniitv. acting pnrsusfil to the direction or authorization of a responsible official of die Disclosing Party, any Contractor or nay A iTiltateri ?-mii> (collectively "Agents").
Page-5 of 13
Ncithct the I >wc losing Party, iso: any Contractor, aoi any AffiJia:cd llo:i;\ of ctthes '.be |)t?cio$:-off !\,.:".> <>: aey Cof.ltaV.or nor any Agent* have, deri-.ig ihe. five years below the dais Ijits h- iS is signed, or, v/ife respect lo ^ Contractor, rin Affi!l:i.u-r! ISr-my. <.¦[ a f:':i:::::7d !\n;;:y of ;i Cr».;;t*!:i^:ii.i:- lioriii1;. ;
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or uncttipiuig to bribe, s public otVte^i" or employee ot ihe City, the Slate of !ttin»ts, or arty tigrnsy of trjt; federal sjovemincn: or of any stars or local goveratucui tn ihe t tnhed Slate* of America, tit thai office:':; or employee's offlcinf capacity;
f>, agreed or colluded with ollte: biddets or prospective bidders, or beeo u party to a ay suck agreement, or been convicted or adjudged aui'.ty of agtacnteni or eolhi.vusi:- zmoi:£ blade/a vs prospective biddies, in restraint of ffecdoct of eninpcritioft by ag: cement io h'tds t"i*cd p:'
c. matte an adrsvisskva of Such condom described ia a. oyh. above, that is a matter of record, but have no; been prosecatcd for socb C-orcduet: or
«•:. violated the provhiiofls. of Municipal Code Section ?-92-Git! (LtvitH*. Wa/v;: Ordinance). _
i, Neither the DiscJusiBg Party. Affiliated Entity or Coshsctor, or ajiy of thctf employee:;, ofTtcrribj. flgeiKU or partners, f? barred! from eonlrac:ris(- with any tfirii of «!::ts or f-r.eaJ •joveitin-.eal as n resxiH of engaging in or bring, Convicted off)) bid-cig.fiimr ill vmtatinn of 73ft ILCK AAlli^; <:&hid.xntmi?iy in— violation of 720 ILCS SA3F.-4; or (i'i amy similar ofterwc of any state or of ihe United States of America that contains the same elements as the offense orbid-riggmg or btd-rouiiftii.
5. Neither the rjisceosioy Party nor any Affiliated Easily is lister! on any of the following its*:; maintained hy the Office of Foreign Asset? Control ofthe US. Departnicat of tEw 'fiewnry or the Bureau of Industry otvd Security of ihe U.S. Department of Commerce or thcii seeeci-t^n;: the Specially Ocusgnatcd Nationals List, the Denied Pcrsotei List, ths Unverified List, the Utility List and the Debarred List.
0. The Disc losing Pany undcrstincls ottd shall comply v/ith the applicable rcixuitemeiitt of Chapters 2-55 (l.ejt|isifttjve tospectox Gcsem!). 2-56 flustjeetox Geeieral) and 2-IS& (Coecrntuenoi litliics) of the Municipal Code.
7 If the Disclosing Party is unable to certify lo ?ny of the above statements (i> this Pari Ii (Farther Certtficniroiss), iiio Disclosing Pony must explain below;
lf-he :v!h:r> " Sr.' th-r- won} "N'otsc." o: at: :c*po;i.v.: ;.{-,.-„«;;. or. -.he iiliv. stove. :• %v ::i he. cu-.:mV.r.:vciy presumed thai rhc Disclosing Partv certified lo the above JVUcment:;.
K. To tbc best of the Disclostny, Patty's knowledge ifter reasonable inquiry, ibc foiinvins is a Complete list of all current employees of ike Dtxciosmp Party who were, at anv time during the i I.-moath period preceding the cxcemioo date of this: irOS. art employee, or elcrtcd or appointed official, of die Cily ol Ciisc.jgo (if none, indicate with "N/A" or "twiic").
Nono
'K 'to the best ofthe Disc5oS!tn; Patty's knowledge after reasonable inquiry, the iollov/mg u: a complete iist of all gifts that the Oisctosinp. Pnrty has given or caused io be given, at any time dtttios the 12-ntontn period prcccdim- the execution date of lids to an employee* or elected or appointed ol'Jieisl. o* the C'u> of Chic:: ^jo. For put pose* ol this statement, a "gift" does not include: (i) anything made generally available to City employee:: or 10 the general piiblic. or Maris
C. CERTIFICATION Oh' STATUS AS FINANCIAL INSTITUTION
The Disc casing Party ccr'.ifies that ihe l)i::clo$ii>i> Party (ebcel; one)
[ 1 is IiO is om
d "financial iiuitituiion" as defined in Section 2-j2-iiS{b) of the Municipal Code.
if the Pisclesing Pany IS a financial institution, then she Disclosing Pany pledget:
'Wc ore not and wiU not become a predatory Ictidci us ucfiocd ia Chapter 2-.TJ ofthe Municipal Code. We further plcdr.c (hat none of oor affiliates is. mid none of them v/ill become, a I'fcdacory lender ax defined in Choplcr 2-32 of the Municipal Code. We understand Hint becoming a predatory iettdei or becoming an affiliate of a predatory lerutei may sestil! in the losi of the privilege of doing hti.tmcss with trie City."
If the Disclosing Puny ii unable 10 make this pledge because it or any of its affiliate!) (:un defined rn Section 2-32-45>(b} of die Montcipal Code! is a predatory tender within the sitcamni! of Chapter 2-32 ofthe rVitrr.reinal ('tide, explain here (attach addi-tioita' page:: if r;eet%sv>*y):
Page '? of IJ
If the icllciS "NA." -he v,m):o "None." or ri'.i .'cspu:!:.« :ir;jv:::!::: or) Ihe SLnr.S ahuve. v.-i11 l>:: .Conclusively pr-.-sur.ied thai the l.>i*e.'o:::nv Parly certified to tire iih:.-ve •;;::!:::::rn.:s
TJ tRTl IMC AT'ON Rf-O. ARMING INT'-P.EST IN CITY JUJSWliSS
Any words ot term.* thai an: defined in Ch&pict 2-136 »i the Municipal Code have :!:e sa-ie mea-Knits v/heo used in this Pan 0.
In accordance with Seeiinji 2-1 5r>-1 10 ol" the Municipal Code; Does any official or employee or the Cttj- have a Ititnttchl ioterttSl iu htts ci: h« owrj fiamc oi in the Jtaaic of any other p«soo or eattiy tn the Matter',*
I i Vrs [<) \0
NOTS: ifyou* checicd ,,VasH lo Item D.L. proceed i» Iichi? aod UJS. Jfytia checked "No* to Item 0.1 proceed to Piir! P
Un*CSS EOld persiiflitt In a pnKCSft of competitive bi-Mni;, or (itherwisc permitted, no City
elected .official o; employee ::halLbavc a ftn:«ie:a! tistcnsi-iii hi.:.or her own nastc os i:i the «at-»c of
any other person or entity its the purcha-ar of any property ihas (i) belong to the City, or (ii) is sold
foriaxcs or assessments, or <)oc*rtetDe-ex the Matter involve a City Property Sale"
( } Yes | I No
Ifyou checked "Yes" to Item 0.1., piovidc the names and business cdihtwses ofthe O'y officials or employee:, having Mich irucrrsM and identify dtc nature of such interest:
Name Business Address Nature of fatcrest
4. The Utnclosinu Party furiJrcr certifies thai no prohibited fmaactal tittcrcst in (he Mutter wiJJ be. acquired by any City official or employee.
B. CERTIFICATION- REGARDING SLAv'JiRy lilt A KUSINBSS
Pttssc cheek cither l or 2. below. If the OiscEosiii" Party cheeks "„ ihe Dine losing Pany in-ist discioic below or in an atutr.hmcni to this KDii all -ufor-natton required hy pani-jraph 2. Kult-ic to
Page-S of i.i
COClipiy with "liesc i.l!:;-."i:>_;i::i-. :i:«;::i;c"i;".ni:; r:::y ;-.i;i!tc a" . C'lTitra-.i entered ifi'.O wilh Lite f.'.'-lv ::. connection wilh ifec Miller voidable hy the C.'.-iv
^ i. The Dtsilosirij: Puny vci ifics ii:u! the rJisciosir;-.; Party has searched any uad ail records of ihe Disclosing Patty ars^ any a;id ii! predecessor entities rci:.ard«>:-: records of :ovcsovicfi;s of profit: from ilovery oj r.iaveliolder insurance policies dorinp. the slavery err} (iocludina iis.sn;ance policies issued to Siavcltoldc:.-. :ha,l provided covcrop-: for tiauifce to or injury or death of lh.:ir aiaves), and the Disclosing Party has found no such rceofdi.
2. The !>LS<-!n:;in.i: Parly verifies that, as a teSult of Condnctta-,.; the :.ear«:h in step 1 above, the Dii.chissi'ijv Party ras found record:; of invcstiaeats of profits from siavciy or slaveholder in'iir.'.r.ue policies. Tile Disclosing Party verifies that the following const twites full- disclosure of ail such recotds. iiieludiat: the nam e« of any and all staves or slaveholders def-ffi'jcd en those record.*:
SECTION VI - CERTIFICATIONS FOR FKHKRAI.I.Y FUNDED MATTERS
VOTKr IF the Mailer is federally funded, complete this Section V!. if (be Matter is not federally funded, proceed ;o Section VS1. For purposes of this Section VI. tax credits allocated by the City and proceeds of debt obligations of die Cily ate riui fedcinl fending.
A. CERTIFICATION P. PC ARDiNG '.OBEY I NO
1. List below the names of all persons o; entities lesristen-d under th:: federal Lobbying Disclosure Act of 19v5 who have rtiade lobbying contacts on behalf of the Disclosing Parly with respect to the Matter: (Add sliced: if itcces.'r.-jryt:
ill ot? explanation appears or begins on the lines above, ot if the letters "NA" or if the \vo-<5 "Norte" appear, it will be conclusively presumed thai the Disclosing Party means that NO persons of coatics registered tt tsder the Lobbying Uisctosure Act of 1995 have made lobbying contacts on Ik half of the Disclosing Party svith respect to the Matter,)
2. The Oiickitiins; Party has not spent and wiij not expend any federally appropriated fundi, to pay-any person or entity listed in Par.ifjrrtpr1. A.), above for his or her lobbying activities or to pay any person or entity lo inftuettce or attempt to infeucaee an offices' us-employee ofany agency, os tic lined by •applicable federal law. a member of Congress, at: officer or employee of Congress, or an employee ol a member of Cou&ivis, in connection with (be. award of any federally funded contract, making any federally funded j-raa- or loan. CJitcrin£ into any eoopctaiive agsectuens, or i«> ex tend, continue, renew, amend, or modify any federally funded eoiv.^icv, i^nni, loan, or cooperatix'e agrecrr.em
Pai^«af
5 Tlw Discl*«aR Pany wiii submit an .,udatcd certification tsi vfic ertd ofeach calendar quarter i-: wbich Acre occur? any event that materially affects the accuracy ofthe atotcmcitu .m! .:. formation &t ?o:ih :;i paroftia|ih:: A.l. and A.2. above,
4- Ts,c Oisclosiui. Party certifies that either Oj it is not at) orgsnfeBlfon described in sestsosi
?0lic){4) of the Internal Kevcnue Code. of ! >»;fv; o; f«> « in a:, or&wation described in section
i0,<«Wof 'n*3**1 Rcvcai* "r 1W» hut tat not e^ttged afitf will no; .w -u.bhvtt;-
Activities". ' * '
3. If the Disclosiat: Party is the Applicant. :i,e Disclosiat; Pany rows? obtain ce»lifH\«i. :a,v Huncoatrjct nod the Discio*,^ pa:ry must mabtain ail jruch tmbcontyactorti' cc-iifetiotH. for the
duration ofthe Matst rind i:iu>i mate ¦inr'i ee:isi';e:-.tior.:; proTOpHy available, to the City upusi r-. ,.:«.>•:
H. CIsRTTFICAT'ON RUGAkDlKCi i-QVnl Si.MPi.OVMliNT OPPORTUNITY
tf the Mattci: is fcderflJly funded, redcrat re-ulattons r«jUfre ,he Applicant arm all proposed sufceontractors to submit the fotlowifty informasion -.vi* d.eir bids or h» writing a/tln: outset or actjutbtions.
In the Disclosing Party lite Applicant?
"rrv« ; 11 no~ ~"~ ~~ "
If ""Yes."* answer the three questions hebw:
1. Have you developed and do ytm have on file affirmative aciioft proems, pwaui to applicable
federal rcjyilaiions? (Sec 41 CHt Pan 60-2.)
fl Yes [ ) No
I. Have you filed with the Joint Reporting Commiltec. the Director of the Office of Federal Contract Compliance Programs, or the l-qnai Eoipbynie.it Opportunity Committor* all reports due under the applicable filing requirement^?
11 Yes l I No
3. Have you, parjicipaJed in any pfevioa* contracts or suucotitretcts subject to the eqttai opportunity chiasc?
\ 1 Yes j J No
Ifyou checked "No" to question 1. o- ? shove, pkase provide on explanation:
P*igc tO of 13
•SECTION VII - ACKNuwLLDCM knt.S, CONTRAO JNCOKPOK.-1TIOV. COMS'S.iA>Ct'-. i'KNALT!i-:S. DISCI.OSvRK
The l)iscfc.?tnr> r*.V-' utrdeistaitd.-: ami
A. i'bc ccrti titrations. dt.-ictoMrrvx. and ac koowlcd&ima-iu:conauoed in ibis I:OS will become part of aav contract or other agreement between :?te Applicant and the Cily iw connection with the. Matte:, uiicthu procurement. City assistance, or other City aciion, and aw materia! inducement:; to the. Cit•••'••. execution of any cotnract or taking oUtci action wisii respect to tiic Matter. The Dv-iclgsia-i Pany ¦i.:nk;-.a::.-i':!i inn! it rnuat .-oniply ill:: ail -tatuiea, ;*rdi:;.:n.;cs. and regulation on which :his h'OS is b-.:Ei. Trie City's Government;:; liibics and Campaiyti h'inaaciittf Ordinances. Clinjitci:: .».• i 56 aad 2-1 r>4 of the Municipal Code, impose certain duties am! obligations on persons oi entities ««x»:ini!; City contracts, work, business, or transactions. Tire full teal of these ordinances tied a ltaiiiini: prosrnrn is available on line at vvww.gitynfehicafeo.C'ra/lithtcs. and may also be obtained fr»tn the City'? ftof.rd of Kditc- 7d0 N.
Sedgwick St Suite 500. Chicago. IL f.OfriO, (312} 744-«>f>Ml. The Disilosim; Parry tnuj-t comply fuUv wilh the appitcabte ordinances
If the City dctcraiiitc.% that any informr-rion provided iu this KDS is false. incojiit>h:ic «r inaccurate, any contract or other agreement in connection wsth which it is submitted mar b.ct may includi- incarceration and an award to she City of treble It is the CityV, policy to make this document available to the public on its Inicnw.: site indAH upo:s request. Some or all ofthe luloitoauoiv provided on litis KOS and any attncbiucnis to this I2DS may ix: made available to the public on th? inccrnct. in response to a Prvudom of Information Act tmpuutt. or otherwise. By completing, and signing this 2iDS, ths: Disclosing'. Pony waives and releases any possible rights or claims whsclt it may have aj;atit.!:t ihe City ia connection with die public release of information contained in this l.\DS and also auLhun/.e* the Ciry io verify the ttceufacy of .my i;tfonno»on submitted in Ihi:; EDS.
II. The inforiitatioa piovided »n 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 flatter, if the Ma.'icr is a contract being handled hy the City's Ocpa tint eat of Procurement Services, the Dhicio^inj-, Por*y must update this I-DS i-s the contract requires. NOTE: With respect to Matter; subject to Ankle I of Chapter 1-2? ofthe Municipal Code {imposing PEHMANItNT INELfClfill.fTY for certain specified offenses), the information provided herein resandinj; eligibility must be '.cut current for:: Joit.scr period, as: required by Chapter 1-23 and Section 2-1 53-020 of the Municipal Code.
The Disclosing Paity represents and warrants that:
Patjc i 1 of O
F.l. The n^cJa^iiie Party i;> s\«t deliih|ut:r.i :n the paymcsu of amy \'->: ::'i;a!DiSleie\: bv 'ive Illinois Department of Revenue, noi are the Disclosing Party or it:: Affiliated Il&ii'i?* delinquent >o paytnj: any Sac. fee. t3A or other c!i:.r»e awe*! *<•< the ("ny. Thiii seduces, Mti t>. hoi limited to. ail '.vstcc chargcv •civcr charges, license fees, parking trc&crs. property taxia's or saUa: mscs.
F-2 If the Diseloiinii Party is I hit Applicant, ihe Diselosstit; Party and its Affiliated lintities ».•: osc. nor ?:-«rtr»i: their subcourrvxtois !« use. any facility lixicrt by she U.S. E.i'.A. on the federal iixctuded Parties List System {"EP1-S',> maintained hy tbe. U. S. Civ.cra! Services Aduiini>;ttttvtnt.
F.3 if the Disclosing Party is the Applicant, the Dkclosing, Pany will :.>r>ic(»ntntcCoir that does not provide such ccjiifietti'ons or that the Disclosing Party hi»s feaaam lobelieve has not provided or cannot ptttvide truthful ec.jtifrcruioits.
NOTlv: If the Di'jclosinp, P^»tly cannot certify a* to any ofthe items >it P.I P.2. o» h\3. tibm-t^ cxpJnjMtJoiy statement must l>t: aurched to this £DS.
CERTIFICATION
Under penalty of perjury, the proton signing below: (» > wjrmals that iuvihe is au'.horu.Mt to caecitte tni* l.tDS ond Appendix A (i.f applicable) on fce&atf ofr.be Dixcfost&g Party, and (2) warrants thai nil certifications and statements contained tn ir is ^"^^Aji^^jf A {if ^^fhu-yu^t^^j^aaa^. — ¦riid ctfr^lcierssufHic'Salc'n.scriisScd to the City.
C'A Ijcsidicrui 1Oo S. WatiMh. I .t.C (Prmt or type nattic-of Disr.losintj Pony)
_.
Tlmaufi M Seen (Print or type name «sf person ssjjning).
AfcUKsaq ftteafcet ofMamyar.
(Print or type, title of person (;ii;,nhigr
(stateh
« esq*.
Signed and swan to before me on (date) Av ¦' / -if , ;»«> / /
County, h'tiaK
Comnmsioii empires:.
Ciw of chkaco
ICCONOMlC mSCLOSURKSTATtMGNT AM) A I'M DAVIT
FAMILIAL KKLATIOiVSIUPS WITH rll.lvCTtfl) CFTV OFFICIALS AiVlJr 1)F.PAKTM.KNT HfcAOS
Ttiis Appendix is to he completed- only in (u) the Applicant, and (b) any Ic-al entity vhfeh has a direct ownervltip interest in the Applicant en-reding 7.5 percent, it is not to be completed fry any legal eiiiit v which has only an imlireci ownership interest In the Apnlicant.
Under iViuntcigiaJ Code Section 2- 5. iJ:e Disclosing Parly nuts ciscfoie v. ltv.iln- such Disctosinft Psm « :-lv "Applicable Pany" or atty Spuatsc :>s Mnmcsiic PartPci thereof cttecittly ha* a "fceftitKit twbixsorshtp"* : lite mayor, :uiy ahieriiian, die city clerk, the city itvasurcr or aay city dcottf intent l*::id as spocw or domestic parttter or any of the following, whether hy blond or adoption: parent, child, brother or sister, audi or uncle. •»<«: or nephew, gmndpatcnt, grandchild, fatber-ie-tow. iriuthea-ia-Saw, :«yn-ip-&uv. "Applicable Party" means (1) all executive officers ofthe Disclosing Patty feed in Section lf.B.l.tu if the DEij.-lo:;rnt'. Pa«y is a corporctiiMi: ail pailncw of tlsc Otfdosiltg Parly, if the Dtsf&xMai* Party ss a *;c?ter.-.i partnership: all gLextcTjl partners aoti limited pcsmicra of the Disclosing. Patty, if the l>isc?rxrii^> Party is a limited partnership; all taaaagciii. nuciagpt?. members and member* of ihe Dtsdasinp. Party, jf the Disclosing Party :.:; a limited liability company; (2) all princqal officer; ofthe DissfctxJBig Pany; and {}) any person having mow tota j. 7.S penpent owactsbipw«*c»in tire Di^tastm*. Party, "Principal efDcersv rosins die pwssutns, chief openttijij officer, executive director, citkf finajic-iaJ officer. treasurer or seui&iry of ofej-al entity or £?.y peison exercising similar authority.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domcsiic Pan net tbcreorcurrently •ttve a "familial tcLiiion.-:hi^" wilh :.n elected city oflluid. or departr-.n";'. had?
[ lV>s JXlNo
If yes. please Idcniify below (I) the name and title of such person. (1) the nan?* of the legit] entity to which such person is: conmtfei; (3) Use nana; and title of the elected et ly official or dqjcmiceni head to tvhom such person has a familial relationship,, and (4) the piccsae nature officii familial relationship.
Page 13 of 13
¦•;TV .:!;:: :a;;;; f.i'yNOMK' DU>CM>K0K£ STATEMENT AND AmDAVrr
a ••'Pi:: . i
P-Vll.Di^: CODE ::C{.i:-n.AlV/rKOi^^:^i LAtfDi.OSU CEHTiKiOVaO
i his Appendix lo be cu:»p;ct«d oaly hy (a* the Applicant, :ind fb) any le&ai entity w»:ei» has a d&ert w>K:«fci?i iC5cl«esi isM-N? Attwlicnat c;.c^;:rj« ~.y pa«!cftl {ait •'Ov/nefJ. ¦ilno; t« hv coffipleivd oy any i-.^ni entity wfeicb ban 0.3 lyes bxttroct ownership Sttevest iv. the A.pp:te:;:ii.
j. Pursu-rnt to N-te'dpai Code .Sct.;vn -M.5-i-tfia hi ihe App::cunl oreny Ov.-nwidcflUikd sxa building ce-dc seolfkiv.- or problem featdHeid piirsaaa* to Sec* ton ?-0:?-"«IG ,-.f lire Mi;;:idp:i! C\sde" "
! ;Ye> Who
_ic App'iicum i.t a Jejsl «euty ptsWiciy iiunotfon ta»y exchange, isajty officer or dLirceftirof the Apf.-lieaot r-tScniiiied as a Duir:Uttg fode seo!Tir;woi- prohvyrn l&tdhaid pursuant lo Section 2-92-Ub ivl the Mswicipsl Code?
| j Yes | | No IX i Not Ap4>l»c:sbfr
5. it yes to i 1} (2) ubo'. c. please icsattSy httow ihe oaote of -.he person «*t tqgai entity
id&iiilisd as a Iwildutg code seofllsw or prcibfcaj fand.^wi jtnd the sddress c'the tutrix u% or fctiiidiiigs. to vvtiicft the ^Tttttcn; code violations apply.
Fli.LlNC.: OUT TtHS APPENDIX 6 COfcVITJrUTHS ACKKOvVI,KDCM*:fi T AND AGRRKMENT'TBAT TOJ55 AfPWOIX B K> tNtfORPORATF.tt IJ-Y REFBRKNC* INTO, AND MAinL A PAST OF, THP. ASSOCIATED E»S. AND THAT TMfc JUSPST^BNTATIONS MADRID THIS APPENDIX « ARM SU&fliCrTO Tlf£ (rtJiTlitC'ATiON MADif. UNDER PENALTY OF PERJIW ON PAGE fl Ofr'TfT.S ASSOCIATED KTJS.
;D0 NOT SlffhM IT Til IS PACT. WlTitVOUR fIDS. Tin- purpose of ihis pat;c is for you to recertify y:iur f-f)S prior io submissiiet to City Council or on i(«- date ofeTorftmj. I Tunable to revertify trutlsAilfy. die I )iscfosijte. Party must complete a new i-OS with correct or corrected intbnnaliotu
R ECKKTlI IC ATI ON
(ici5:;raJi> . li'-r itsc with C'iiy Council matters. \m Tor City procurement* unless rcqteMerf.
Manned IV.'clupsih.tii for l|}!i- -0S. Wabash A»v'?.fc i - Koowti R.d. This recertifies! ioa i> beir.j;. submitted in connection wilh
| edenti fy the Mat tcrj. Under penalty of perjury, the person signing bclov.: (1) wanan; thsi he/she is authorized to execute this FDS twortirtratton on behalf of ihe Disclosing Party. (3j warrants that all certifications 2nd statements oontatntd in the Disclosing Patty's orifti.11.9l i.il.XS arc true, aeeumlo and complete as ofthe dale furnished 10 the City continue £0 he tire, accurate and co:up5e4c as ofthe date of this reocrtificaiivn, and rcaftimts. its acknowledges.
11 Seuiti ttahssh. l.l.f
(Print or ivpc letytl mane of Disclosing Parly)
; A/OA
(si«nl»Qe)
Prim or type nante of signatory: Keith GiU-i
Title of signatory:
Signed and sworn to before mc on {date} .£*>*l J-'i , by
Keith Ctlrs . 3. <<>ofc ' Ci/mty/' [<*.;1c|.
{ jIAA/^*^^-^—-- Notary Public.
Commission expires:
{!>0 NOT SUBMIT THIS PAGE WiVll YOUR EDS. The puW- of this paye is l<«; you t;i r».:Ccitify your HDS prior lo submission to Oily Council or on the ti:jjc or closing i! i:;::ibiv rcccmly truthfully, the Disclosing Party nam complete a new EDS whit correct or corrected
Mifl.H-iiiallOfl!
RF.CKft 11 RCATlON
f'i«nerany. for use uiib Cily Coaitci! mttten. No? for City rKwurenrents utiles*; roqrotcdL
I'ij^uvJ O.noispff.T.; t«>i ItJtj- W ii. UV>I.M»t> A«c::6 f. tW,nvi fel.
Hiis rcxxaifusitKMi is being subnijtted in connection with
[identify tho Mstterj. Under penalty t>rpcriory. the pesson sign ins, below; fl) wajrar.uTiiai bc/shc h: zsttarna'i to execute this I'iOS reccrti!tcslio;i *yn behalf of the DmIosws Paitv, {7.) warrants thai all certifications and jtstctnems contained in the Disclosing Party's original IfDS arc tr»ic. accurate and complete as of 1hc date fumisbed if the City end cooiini'e to be true, narrate and complete as of the date of t his rcccnifksttion. aiid (_V, reaffirms 5t.s .: ci>*notv|ediyneiii>.
_VAXC. ii.tfe&*M3y,ll£ . Dale; JyU , tC/b
(Pastor type Ici-ri! nirac of Disclosing Prtnv) V * ""*'*
f \ - • P.
isigalieif) Print or type isarne of signatory:
Kdfe Giles Title of sijTiatory;
Manatiet
ShgK-d and sworn in before tar on {datcf ^fsJ.__^3._?£>_/& by
.JSSlS!?! at Cec* iJccumy. _jl&i?ffi fs!ste|.
Idddd^^-'^s^- ~ KotaryPkiMtc.
Commission c.vpitu%:
Vcr. l«l^ OlHCfAtSIM.
MciaryPuls.s • sisk u»iflo:s
Cn..- "la-. ^ 5f
(.00 NOT SUBMIT THIS PACE WJTH YOUR EDS. Tbs purpose of this page is for you to recertify your EDS prior io submission to City Council cr cn ihe date of closing If unable to recertify rrudiftdiy, ti:e Disclosing Party itmli complete a new EDS with eoncet or corrected i.n.fonn2.t:or.}
RFX:F.U.'l it'TCA llO.N
Generally, R>r use wish City Council matters. N'ct for City procsuf.v.ems rrrvicss rcquestc^
Planned Onvele-isiicol for ! 136 - 40 S. <.'.'ihis'i Aviv26E. Rcoicv*ll Us.
This rcL-crtificjuion is being submitted in conrrcaion. with.
[identify die Matter). Under penalty of perjury, the person signing below: (1) wnrranis that bs/sbc is authorized to «ectrtc this liDS rcccrtification e;i behalf of the Disciasinit, Party,. (2) warrants that all certifies.! iorts ;tnd siatcmcnts contained in the Disclosing Party's oritinn.-il EDS arc Toe. accurate and contplctc as ofthe date furnished to the City aad con-iCLi* io he true, Accurate end complete as of ihctkiie of this rcvcrtificazion. and (3) rciiflirEii; its. acktiov.lexiyrnents.
CA Rcsn-vntial i 136 S. tt^asa, t .1X ¦ _*J- [
(Print or rypr lc£;al name of Disclosing Parry)
tty:
'(^^hcref)^ Print or type nsm« of signatory:
^DMft£>_^, SiLCi-kz
Title cf signatory.
Signed aid sworn to before me oa [datcj^t^Ji \, _ QjjLi t <2£M oby
'T&nu.Q,'-. U . W/rfdr . ra Cook ' " County, r^±_
CuOfiP A y Notary Pubiie. Commission expires: ( " (~ ( ~7
•OFFICIAL SEAL*
vj Carin Casper
L
~ Noiaiy ruDEc, S"v.c; of lllinoi: My Cornrni-csiCJrt ExpiresWlSffiff
(DO NOT SUBMIT TillS PAG!' WITH YOUR F.DS. The pvrposc of this page :s for vou t«> recertify yoi:r EOS prior to submission to City Council or on the date of closing, ifutab:? to recertify i.-uthfuliy. the Disclosing Patty roust complete a new UDS with correct or corrccrec-imonnaiiorv,
K£CERTrFICATlC.V
C-eecraiiy. for us£ with City Council sustUs*. Noi for Cir/proeirrt^ients usbss «o,ae«ed.
Pi3n.-7e.-i rtevetopoicnl for 1136 - *Q S, VVitoA Avr.Oil R. RoMvvrll RJ.
This reccntftcatioa l>- being subauctcd ir. eo:a.teotjoa with
{identify the Matter}. Under penalty of perjury. Uie person signing below: (1) warrants that lie/she is authorized to execute ibis CDS icccrtificttton on behalf of the Disclosing Party. (2} «Bftan;s thai all ccrJficaa'ons and stotesicnu; caaisL-red in ihe-Disclosing-Party's original F.D.S sre ^ accurate .tnd complete as of the date gasL&ed to the City and Usance to be tnic, accurate and compter, as of the date of sJtis recertiikauac, and (3) reaffirms ks iiclmowledgtrieitt.':.
CAtegtefiiXtXC ^ D31C.
(Prim or type, legal name of Disusing Pair/}
-Svi
f tstga-b'crc)^''/'
Print or type name of signatory:
.IWwto fl Scoff
Title of signatory: My/tajsrg Mcroior of Jkiwsgee
Signed nstj sworn to before irie tin fdatclftgUl TA/I&Ujs . by
VtAALO (jl/j^Xi^A J Notary Pub!!:.
Commission expires: / — { CI *- / ~"J
'OFFICIAL SEAL"
v„.,«w g Carin Casper J
(DO NOi SUBMIT THJS PAGE WITH YOUR. UBS. The purpose of this pap,c is for you to recertify your EDS prior to submission to City Council or cut the d-ste of closing. If unable to recertify truthfully, t;n: Disclosing Parry must coojpleic a cc* EDS w$tb correct oreoirectcd irvformatica)
ti 1-X- M KTIFI CATrON
General!/, for uk vj-iih Ciry Couqsu rnarrcrs. No: ¦"<;.- City procurcntcnLS unless requested.
Ptoewd Devcb|X7::u for 1136 - -This rcccrtificaiion is being submitted ip connection with
LSderdify the Matter). Under penalty of perjury, the pcrsort signing below. (1 j winnnts that he/sbe. is authorised to execute this EDS t certification on hclialf of the Disclosing Party,. (I) wwraas that all ccniflcattons and statement.*: eoahtiaed in the DL«h»trtg Pony's o-ricjin.il EOS are true, accurate and complete rs of tie date fijfa&bcd to the City &rJ CMr.iinue to be true, accurate and complete as of the d:vtc of this receitinciiirirj. and (3) reaffirms its acknciwlcdgtoesls.
(Print or type Icpri! t^rtis of Disclosing Party)
">c-
(sign hew) , .
Print or type, oajne of signatory:
Title, of Signatory: Mtuugbn Monlci of N&rager
Signed and.wortj to before me on [daiaAffiJ I 2ft, 20(ifi . by
V^OMfrt> U-jClefcb-.a c«oL- County. „:¦¦,„•, |stfccJ.
LlAtiUU. (ttiSyftf A J Stately Public
Con^rnksiort expires: ij[ .
- , . Vci. M^Mlli
{ "OFFICIAL S£AL*
v. Cafin Caspar|109|Notnp/ Pubic. Slitt Ot HttraecB
> My CW^sjonExp^f-g ^^gPAi.
(DO NOT SUElMlT THIS I'Afi F. WITH YOUR KUS. 11»c |X*p<*.-. ol'vtiis pj$r, ij. fur ywi io recertify yrar IICS prior to Jirfcrnbsiao to ChyCuacil cr oo the ill? of ctosir^. if um&1.*. :n recertify tr.nl'.rully, (lit Dijclojinjj r.-rty tnm* cwnplctc n new EDS with earrcrt orcorrcetcc ir-fcrrutianl
RltCKrtTtKlCA'rlON
Genially, foe use wjOi Cily Coviidi mstifaS. Nut
t^irtd f*w tstromifor «l?S- \vciS6 U. KcoUi tIi RJ.
This rccerufYcaticrn is birnj submitted in ccREceipo with
(identify diz Metier}. Under pcrjlty of perjury, the pcrsna agnirs; bc£>w: (I) vtmran that lie'r,Si ir. rAflhOfttecJ to csceulc Otis KDS icctllilicalian c:i behalf ofthe Diicl-.'sing Party. (2) warrant; thai til cettificJiiorj; tti'ui stfi;fyr.etiis cccwdncd hi tht DtSrSOSisr Pliny's ati^'ral EDS -c true, areitistc and cetnplctc ns of t'tc dole fiinihhcd io (he Cfcy mi cwittr-vc to hi tort, afcrais led ectnpJctc cs cf date oT lias riMrafieisJan, and (3) rcaffrnni its si&iiowlnluReifiS.
CA Mmn.tr . H.C
-£Pnfltcet\'js-tcKa1 pjirjc^f-r^s^irsjpariy}-r»v
Pries ar type nunc of signatory? TTianM M. Scnli
fids af signatory:
Stpncd =itt j'.vom to tifcte MIC OH (drtl«K;/^ ,?.*?-(t$_ „. by
T>na;yt4 ifeti .at Cwfc * Ccttgy. "* l«a^e],
' I ' X '
Gtneafcshnt ctphca / ** /-J/"*" / ~1 .
{ "OFFICII. SEAL"
L
" Wulnsy PuKi:. Ktcta ol 4!r;ds
(S.10 NOT SUBMIT THIS PAGE WITH YtXiK tDS. The pep^ of a.* fu^c is foe vtxj if: rowrnfy year CDS prior io siibcr.isnoa fa City Council or an ibc ivnlcirfclof-inj;. Ifmiblc ;o reccnify iftfihfully. thr Discicsifltt Ptity mua cantatas n new EJ>5 wilh correct tn eontcicc infarsution)
KKCfcRTIFlCATJON
Gcnnally, for use. with Ciiy Coui'-cit matters. Koi for Gty procurvosas liftles; invucstcd.7
^ PUuttf D«cJa,TrKrsfor |li£-«S. V/Uah Ave/,'! IL Hftcfi^MllKd
This rcccrtifrtaiiun b being, MAiactclt io croncrtion vyhh
{identify th; Miticr{. Undrr penalty of pfcrjery, the person waning befou-: (l) wfrnatrSiM iisShc is authnriircd 10 cxcnilc Otis EDS lecctdttcMiuri oo bdulfof the Inclosing Paly. (2) >4Mi r^jfis that t!l cettirtcatiOK.*. nr:) saicmcnts coni&mvd fa the Di** losing PxtTy's orieisai P.DS arc irui, wewitrate and complete *s ofthe date fam;d*ii to (te City and continue io be trot, icceraic arid eympfctc as of die tUi.e of llii"^ rcocrtificisiofl, and (3) reaffirms its jciuiowfcitgrrtc*)'!.
C SS-'ll MU »"wr% 1VT q,lV\W
(IfiiM ttr type legal name of Olsstolins Pany) "*~
?rinl or \y^t vans, of sSgratiKy; Tteain M. Seep
T&lc Of iignitcry: 'I'rresfr:
Ssjnoi sod tMicnt to before etc cn {dai.e j J!L Li fO, , by
Ttc.nmM.Sca3 ^ , t, Cotfc. ' J Couch', nr„~l, |sialc).
Carscnictiocj ctfiireJI , / " / >- /
f "OFPlCfALSnAi.'
V Carirt Casper
•DO KOT Sl.'HMlTTHlS PACE WITH YOUP. TDS. Tte jmrjivic ofth:; par;c ij frrynii to ^certify vo jr CIDS pmr to EiibiiviSsian lo City Council or org tlic tltrtc of doling. If imibl= :r, recertify liulhfi£':y, the Dhe'.owis pany uiui: cOrnpictc a new F.Di u'itli eoirttt or coerceta: infornMiicml
RVXFJITIFICaYION
cicr>:fj;1iy. far use wiih Cily Coancff numer*. Not tor CS.'y procurcmii«; unksi t equaled.
TtittNS fttcVpneci tlu- f 134 • This rc;ctiifl«ni5os is being, Stttenined ia cormtefifjo yiith ____
tiasrrtiry ifcje Nfaf.ttJ. Under penalty of parjary. tin jiftSco ifjniaf* bctcrw: (IJ wttnis"tlla te-alic is 3u£>nri>;a3 to execute lliSs CDS rcceruficK.ion On VtfiiiSf ef the Dircl&ting Kirty, {3) vsunaas list ail caiilWutiiins Sr-d statements contained in the Oijclasiitg Party's criofeui ROS r*: tr.>r. accurate and cnoijilctc as of Hie dale furnished to ihe City o.i
frciUfrnilyTrua ^ rjsll, *4-27-
. (PiIaiAtLtjpsJc^tosi3ii^W)itdosinj;-F I!!^1.
By: / | / ¦>¦-'"
E*~=hsc)/
Pirtiit * type era: of sipiatary:
Tll!c Of signatory: 'liinij?
Signed or*) suoot u> before tnc On {diic} tJr~2:t w by
Jii&'iJiiiS^--^ , .»«-C"dt' ' Coige7,_.?/^ rIt2,-j.
Conunisito.Ti c.ip>rei: \ - I /
i 'OFFICIAL SEAL"
I Caw CyC-psr.
City or chk.aco
ECONOMIC DISCLOSURE STATEMENT AND A KIT DAVIT
SECTION I - GENERAL INFORMATION
A. Legal name oi" the Disclosing Party submitting this EOS. Include d/b/a/ it"applicable:
Christine Skiih::!: K«vYtC<
Check ONE of the following three boxes:
indicate whether she Disclosing Party submit: tog this HDS i.s:
[ j ihe Applicant
OR
L\] a legal entity holding a direct or indirect interest itt ihe Applicant. State the legal name ofthe
Applicant in which the Disclosing Party holds an interest: 26 Hast Rf*«cvL-.it. i I C
OK ~ " ' ~
3. [ 1 u legal entity with a right of control {see Section K.B.I.) Stale the legal name ofthe entity in
which the Disclosing Party holds a right of control:
ft. Business address of the Disclosing Party: MS6 KStfac Kcmd
II:«hland Pari:. IL 6u!X3S
Telephone: 3i2»«6-W7 Fax: . Email: jtib»dti&ttflaan<«
Name of contact person: Rolando it. Acosta
K. Federal Eaiployer Identification No! (ifyou have one): '
E. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this 80S pertains. (Include project number arid location of property, if applicable):
Plrancd Dcvcloptnetu for 1136 • 41) S. Wabash AvcJ26 IL StoaHcrcli R<>.
G. Which City agency or department is requesting this EPS? DPP
If" the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification it and Contract ii _
Pag;: 1 of 13
SECTION U -DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE* Of- THE DISCLOSING PARTY
I. Indicate she nature of the Disclosim'. Pan/v:
[ ] Person
( ] Publt'cly registered busiticss, corporation
1 ] Privately held business corporation
[ I Sole proprietorship
[ ] General partnership
[ ] Limited partnership
[X'f Trust
[ ) Limited liability company • j Limited {('ability partnership I | Joint venture f j Not-for-profit corporation
(Is the not*for*profit corporation also a 50lfc){3))?
f j Yes | j No
\ | Other (please specify)
2. For legal entities, the stale (or foreign country) of incorporation or organisation, if applicable:
lilirioi:;
3. For legal entities not organized in the State of Illinois: Has the organization reijbtcrcd to do business in die Suite of Illinois as a foreign entity?
t I Ves { ] No N7A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
$. List below the full names and titles of all executive officers ,1ud all directors ofthe entity. NOTE: For not-for-profit corporal ions, also list below alt members, ifany, which arc legal entities. If there ate no such members, write "no members." For trusts, estates or other similar entities, list below Ihe legal tlltehoider(s).
if the entity is a geucral partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the flame and title of each general partner, managing member, manager ar any oilier person of entity thai controls the day-to-day management of the, Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Crisfins Giles Tnsjtcc
2. Please provide the following information concerning each person or entity having a direct or indirect beszcHcml interest (inc luding ownership) in excess of 7.5% of the Disclosing Parfv. Examples oi such an interest include shares iu a corporation, partnership interest in a partnership ot joint venture.
Page 2 of U
interest ;>! :i member or manager in limited liability company, or interest of a beneficiary of :i
Name f'iusincss Address Percentage Interest in tho
Disclosing Pany
Jl&Bafes Road. W
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Pany had a "business relationship." as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the 12 months before the date ibis EDS is signed?
11 Yes WNo
If yes, please identify below the name(s) of such City elected oflicsal(s) and describe such relationship^):
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES'
The Disclosing Party must disclose the name and business address of each subcontractor, a ttorney, lobbyist accountant, consultant and any other person or entity whom the Disclosing Pany has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is noi required to disclose employees who arc paid solely through the Disclosing Party's regular payroll.
-Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than; (I) a not-for-profit entity, on an unpaid basis, or (2) himself. ""Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
sf the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must cither ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business Relationship u> Disclosing Party Fees (indicate whether
retained or anticipated Address ('subcontuictor, attorney. paid or estimated.) NOTF.:
to he retained) lobbyist, etc.) "hourly rate" or "t.h.d." is
not an acceptable response.
(Ado sheets if necessary)
Nf ( 'heck here if the Disclosing Party has not retailed, aor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPUAMCH
Under Municipal Code Section 2-V2-415, substantia/ owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in
-arrcnrage-onany-ehild suppori-obligalions-by^ny-niiftoisxoTm-aPcompcfcnrjxirisdrction"?
[ J Yes (yj No f ) No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes." has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
CI Yes (} No '
FURTHER CnRTlEJCATIONS
I. Pursuant to Municipal Code Chapter J-2.1, Article I ("Article I")(wh»ch the Applicant should consult for defined terms (e.g., "doing business*') and legal roqujtiettjcnts), if the Disclosing, Party subtnitling ibis gt>$ is the Applicant and is dtoteg business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of. or has ever been convicted of, or placed under supervision for, any Criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, foigerv. perjury, dishonesty or deceit against an officer or employee Ofthe City or any sister agency; anrt (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City, NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I Supersedes some live-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
2 The Disclosing Pari} and, }} the Disclosing /•'arty is ;i legal ernilv. aii o; those persons or cntirics mcntificd in Section II.B.I. of this EDS:
arc not presently dcharred, suspended, proposed lot debarment, declared ineligible or voluntarily excluded i'rom any transactions hy any federal, state or local unit ol"government;
have noi. within a ftyc-ycar period preceding the date of this l.?.OS. been convicted of a criminal ot tense, adjudged guilty, or had a civil judgment rendered against them tn connection with: obtaining, attempting lo obtain, or performing a public (federal, stale or local) transaction or contract under a public transaction; a violation of federal or stale antitrust statutes-, fraud: embezzlement; theft; forgery: bribery; falsification or destruction ol"records: making false statements; Or receiving stolen property:
are nor presently indicted for. or criminally or civilly charged by. a governmental entity iichave noi. within a five-year period preceding the dare ofthis EDS, had one or more public transactions (federal, stale or local) terminated for cause or default; and
have not, within a five-year period preceding the date of tilts EDS. beers convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
3. The certifications in subparts 3, and 5 concern:
die Disclosing Parly;
" any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Pany in connection wilh the Matter, including but not limited to all persons or legal entities disclosed tinder Section I V, "Disclosure Of Subcontractors and Olher Retained Parties"):
any "Affiliated Entity'1 (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by rhe 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 direcsly or indirectly controls the Contractor, is controlled by it, or. with the Contractor, is under common control of another person or entity;
any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Rntity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorisation of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively ""Agents"1).
Neither .'he Disclosing Party, nor any Contractor, no/ any A ffiiia.-eri Entity of cither the Diselosiag Parlor any Contractor nor any Agents have, during the five years before the date this F.DS is signed, ot. will rcsncct 10 a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five ycais before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted io bribe, or been convicted or adjudged guilty el" bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local govern men I in the United States of America, in thai officer's or employee's official capacity:
agreed or colluded with other bidders or prospective bidders, or been a parly 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 lo bid a ftxcd price or otherwise, or
made an admission of such conduct described in a. or b. above that is a mailer of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agent* or pannw>\ is barred irom contracting wiDTanyuful or state or local government as a result of engaging in or being convicted of (1) hid-rigging in violation of 720 ILCS 5/33E-3: (2) bid-rotating in violation of 720 ILCS 5/33 E-4; or (3) any similar -offense of any slate or ofthe United States of America that contains the same elements as the offense of bid* rigging or bid-rotating,
Neither the Disclosing Party nor any Affiliated Entity is listed on any ofthe following lists maintained by the Office of Foreign Assets Control ofthe U.S. Department ofthe Treasury or the Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative inspector General). 2-56 (Inspector General) and 2-156 (Governmental Ethics) ol the Municipal Code.
tf the Disclosing Party is unable to certify to any of the above statements in this Part D (Further Certifications), the Disclosing Party must explain below.-
I f the letters "NA." the word "None" or no response appears on "die lines above, it will be conclusively presumed that (lie Disclosing Party certified to the above statements.
X. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the followiipj is a complete list of all current employees of the Disclosing Party who were, at any time during the 1 2-month period preceding the execution date of this FIDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" ot "none").
None
*). To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following ts a complete list of a!! gifts that the Disclosing Pany has given oi caused to be given, at any time during the 12-month period preceding the execution dale of this EDS, to an employee, or elected or appointed official, ofthe City of Chicago, for puiposcs of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 pet recipient (if none, indicate with "NAV or "none"). As to any gift listed below, please also list the name ofthe City recipient.
None
C. CERTIFICATION OH STATUS AS FINANCIAL INSTITUTION
?. The Disclosing Party certifies that the Disclosing Party (check one)
| | is Dd is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing Party IS a financial institution, then (he Disclosing Party pledges:
"Wc arc not and will not become a predatory lender as defined in Chapter 2-32 of ihe Municipal Code. Wc further pledge that none ofour affiliates is, and none of them will become, a predatory lender as defined to Chapter 2-32 ofthe Municipal Code. We understand that, becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."
If the Disclosing Parly is unable to make this pledge because it or any of lit? affiliates (as defined in Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
Page- 7 of ] 'J>
11*the letters "NA." the word "None." or no response appears on ihe hues above, if veil) he conclusively presumed that Ihe Disclosing Party certified to the above statements.
D. CH RT IFIC ATION RI-G A RD ING INTEREST IN CUT BUSINESS
Any wotds or terms that arc defined in Chapter 2-1 5n of the Municipal Cede have the xamc meanings when used in this Han D.
In accordance with Section 2-356-1 10 ofthe Municipal Code: Docs any official or employee of the City have n financial interest in his or her own name or in the name of any other person or entity in the Matter?
H Y es fc) No
NOTE: Ifyou checked "Yes" to Item D.l... proceed to Items D.2. and D.3. Ifyou cheeked "No" to Item D.I... proceed to Part E.
Unless sold pursuant to a process of competitive- bidding, or omcrwisc permitted, no City elected official or employee shall have a financial interest in his or her own name or jn the name of any other person or entity in the purchase of any property that.(i) belongs lo the City, or (ii) is sold
lor tases_.Qr_a^^
"City Property Sate"). Compensation for property taken, pursuant to the City's eminent, domain power docs not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Property Sale?
r ] Yes [ 1 No
3: 11* you checked "Yes" to Item D. I., provide the names and business addresses of the City Officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest.
4-. The Disclosing Party further certifies that no prohibited financial interest in the Mailer will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2 the Disclosing Party must disclose below or iu an attachment to this EDS all information reouued hy paragraph 2. Failure to
Pane i? Of 13
eor:!;;iy with these disclosure ;cquire:ncr;s.s nifty make any contract entered into with the (Jiiv in connection with the Matter voidable by the City.
* 1 ¦ The Disclosing Party verifies that the Disclosing Party has- searched any and al! records of
the Disclosing Party and any and all predecessor entities regarding records of investments or profits trom 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.
The Disclosing Party verifies that, as a result of conducting the search in slep ! above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Patty verifies that Ihe following constitute? full disclosure of ai! such records, including the names of any and afl slaves or slaveholders described in those records:
SECTION V I - 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, ta* credits allocated by the Citv and proceeds of debt obligations ofthe City arc not federal funding.
A. CERTIFICATION REGARDING LOBBYING
L List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contact* on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on bchalfof the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds lo pay-any person or entity listed in Paragraph A.l. above for his or her lobbying activities or lo pay any person or entity lo influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law. a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract making any federally funded grant or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded contract, grant. loan, or cooperative agreement.
Page ° of 13
1 The Disclosing Pany will submit, an undated certification at the end of each calendar quarter j~ '-.'inch there occurs any event that materially affects the accuracy of the statements and in formation set forth ni patagraphs A.l. and A.?., above.
-i. The Disclosing Party certifies that either: fi) it is not an organization described i.u section ¦Qlirt(i) ofthe 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 no! engage in "Lobbying Activities".
5. It the Disclosing Party is the Applicant,.th.c Diselosirvj Party must obtain certifications equal ir form and substance to paragraphs A.l. through A.4. above from all subcontractors before il awards any subcontract and the Disclosing Party must maintain all such subcontrncro.-s' certifications for the duration ofthe Matter and must make such certifications promptly available to the City um» request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Mrmer is federally funded, federal regulations require the Applicantnod ail proposed
subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
TsThTTDilclbsing .PaTtylue Applicant? r "
r I Yes f ] No
If "Yes," answer the three questions below:
<. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 00-2.)
( l Ycs [ I No
Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under Lhc applicable filing requirements?
I 1 Yes I I No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ 1 Yes [ 1 N'o
Ifyou checked "No" to question 1. or 2. above, please provide an explanation;
Page 10 of n
SECTION Vil -- ACKNOWLEDGMENTS. CON TRACT INCORPORATION. COM P LI A N CI %, PENALTIES, DISCLOSURE
. *.-c iJ:sc!ost;lg Pari.y uwicrsnn.d'.s and agree.*: thai:
The certifications, disclosures, and acknowledgments contained in this EDS will become can of anv contract or other agreement between the Applicant arid the. City in connection with the Matter, whether procurement. City assistance, or other City action, and are marcrial inducements to !.hc City's execution o: any contract or taking other action with respect to lite Matter. The Disclosing Party understands th;-: it must comply with all statutes, ordinances, and regulations On which this EDS is based.
The City's Governmental Ethics and Campaign rinaueiug Ordinances. Chapters 2-E56 and 2-1*64 of the Municipal Code, impose certain duties and obligations ou persons or entities seeking City contracts-, work, business, or transactions. The lull text of these ordinances and a training program is available on
at vvjafw.eitvofehicagororr./Etl.ii<^-. and may also be obtained from the City's Board of Ethics. 740 N.
Sedgwick St., Suite 500, Chicago. IL 60610, (5121 744-9660. The Disclosing Party must comply i>*lK with the applicable ordinances.
if the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contiact or agreement (if noi 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 Parly to participate tn other transactions with the City. Remedies at law fo; a false statement of materia? fact may include incarceration and an aware: to the City of treble damages.
it is the City's policy to make this document available to the puhJsc or: its (ntcntct site and/or upon request. Some or all of the information provided on this EDS and any attachments to tins EDS may he made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and ajso authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided ir. this EDS must be kept current. En the even! of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If die 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: Wilh respect to Matter]; subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept, currenl for a longer period,
as re-quired by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants thai:
Page 1 i of 13
1 . i. 'i iu- Disf.Ur.ii:-.: Pany is not (icl!i!i:i:eiii iii the payment ft' any tax administered hy tl-.ir f Ili-ioi-s .Department of Revenue, nor rtrc me Disclosing Party or its Affiliated lintitics delinquent pttyttu- any fine. lee. [.'•¦- o; !.:!:<:: t: barge owed to the i "siy. Tfvs includes. Inn is aoi limited to. all .vai.\r ehrr-rsct,. sevt.-t.-r chatlicense fees, park i«g tickets, property taxes or s;it«s taxes.
'*'•» 'I'the Disciitsitig Putty is Uio Applicant, the Disclosing Pany and it-, Affiliated Kntiiicr. wilt not i»*e. nor permit sk.i: subcontractors to »«:, any facility Sistcd by the U.S. UJ'.A. on the icdeittl l-x eluded Panics List System ("l?P!S") maintained by tin; Ii. S. CicncraJ Services Adnunisuasioii.
i\} if ihe Disrfnsing Party is the Applicant, the Disclosing Party will obtain from am conuactor.vswbcontractors hired or to he hired in connection wiih the Matter certifications equal m form and substttnee to these in P.I. and above and will tint, without the prior written consent ofihe Cn>'. use any such coatrnctor/siibcomractoj thai docs not provide sneft certifications or thai the IJisclniiny P:t;ty h:ts rcasou to believe bas not provided nr cairnoi provide irmiiiul e^nific-.tiojis.
NOTE: N'lhc fi is*, losing Pany cannot certify ns- to any ofthe items in l\t,. l»\2. or'F.3. above, an explanatory statement most be attached in this lil>$.
<:t;KTIF Ft" AVION
Under penally of pc-sjiuy. the person signing below: (I > warrants «t:;ti 'i-.v'she is authorized io execute
certifications. and .suttcinsnis contained hi this 6D$ and Appendix' A niraginv Sbtinik far.wtmac Trust dtatil September I (>, 201M! (Print or type name of Disclosing Party)
By: ' V
{Sigr. here)
OwtEw-ftitV* "StoAvU-{Prinl or type- name of person signing)
T-iwtcr
(Piinl or typo Itlle of person sijjniny)
Signed and sworn to before roe on (date)> "^y
ai .Cgok_ ^ County, l!1'-"'Qis ifKxv).
Notarv Public.
H QrflClAl. SzM|109|t/.iilJMOA UWHtNCL *
»V3tc;y Public • 'State ol Miacis- ?
My Comrr:;ss.lori tjpttcs S-.? "j. 20t7 ,
& sj yj 'W u '¦i1 'C U,'"UF' IV W ^
CITYOFCHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH El.Ef.TKI ) CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not tn be completed by any legal entity which bus only an indirect ownership interest in (he Applicant.
Under Municipal Code Section 2-154-015, (lie Disposing Parry must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse Or Domestic Partner thereof currently has a "familial relationship" with --ny elected city official or department head. A "familial relationship" exists if. as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law. sicpfathcr or stepmother, stepson or stepdaughter, stepbrother or stepsister or haif-bi other or hal.f-sist.ct
"Applicable Party" means (!) all executive officers ofthe Disclosing Party listed in Section Ii.B.l.a., if the Disclosing Party is a corporation; all partners: ofthe Disclosing Party, if the Disclosing Party is a general partnership: all general partners and limited partners of the Disclosing Pany. if die Disclosing Patty is a limited partnership; all managers, managing members and members: ofthe Disdosinr; Pany, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Parly: and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thercofcunxntiy have a "familial relationship" with an elected ciry official Or department bead?
I I Yes IXJNo
If yes. please identify below (1) the name and title of such person. (2) the name of ihe legal entity to which such person is connected; (3) the name and title ofthe elected city official Of department head to whom such person has a familial relationship, and (4) the precise nature of Such familial relationship.
CnVOFCHICAC'O ECONOMIC DISCLOSURESTATEMENT AND AFFIDAVIT APPENDIX K
BUILDING CODE SCOl-'KI.AW7PROBIJiW LANDLORD CERTIFICATION
This- Afipendix is to he completed only by (ai the Applicant, and fbj any tejjal entity which has a direct oirncrship interest, in the Applicant excelling 7.5 percent fan -0»»n«:r^). It Ls not to be eocnpiefed by any le&d entity which has only an indirect ownership int«-ii;-sJ in the Applicant.
1. Pursaant to Municipal Code Section 2-\$4-010. is tlic Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92^416 ofthe Municipal Code?
No
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a" building coiloscofilawor problein landlord purseant to Section 2-<>2-4t<5 ofthe Municipal Code?
P] Ycs rn.No |xl|>'«{ Applicable _ _
3. If yes to (() or (2) above, please identity below the name of the person or fegaJ entity
identified as a building code scofflaw or problem fandfoni and tire address ofthe building or buildings to which ihe pertinent coda isolations apply.
FILLING OUT THIS APPENDIX »S CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX It IS INCORPORATED DV REFERENCE INTO, AND MADE A PART OF,THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX U ARE SUBJECT TO THE CERTIFICATION MADE UNDER PEN ALT V OF PERJURY ON PAGE 12 OFTHE ASSOCIATED EDS.
fcivc !•¦?<...' l-t
CI I V OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing, Party submitting this CDS. Include u/h/a/ if applicable: CA M:i:iavcr. LLC
Check ONE of the following three boxes:
indicate whether the Disclosing Party submitting this EDS is:
f j the Applicant
OR
[ ] a legal entity holding, a director indirect interest in the Applicant. Stale the legal name of the
Applicant in which the Disclosing Party holds an interest: _____
OK
3. [x] a legal entity with a right of control (see Section ll.B. I.) State the legal name of the entity in
which the Disclosing Party holds a right of control: Ui^*:b.3_&lS3hLLC
B. Business address of the Disclosing. Party: 161 N. Clark St Suite 4900 _
OiiGi;»JL60Telephone: 3l2-63fe^V37 Fax: , Email: j^fa$23SSa&^.vg£
Name of contact person: KtUandoK. Aetata
f Federal Employer Identification No. (ifyou Isavc one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
i'lnnnsd Development for 1136 - -10 S. Wabasltf26 F. Roosevelt K.!.
O- Which City agency or department is requesting this EDS? DPD . _
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification U and Contract fl
Vcr.Gt.oi-U Page I of 13
SECTION 11 - DtSCt.OSl.TtK OF OW-NERSlHP INTERESTS
NATiyR!: Ol- Till: DISCl.OKiNG PARTY-
!- Indicate ill" nature oi I.!:'.: Djsclv,.-;hi£ I'iVily:
[j Person >;<] Limned liability company
( I PiJt.>!;;;iy iVL;:sicr::c! iji)::;ri!-i;: ctirporalioi; ( | !.f.mii.:i liability pariuc'slvip
[3 J'tivaicJyluiiij biisiiicss csi:pc>r-iio:i j i Joint vetihtnr
ii Sole prop/ktorsiti).* ( { N'o! for pfofU ::orpo!^ii«r;
f J (isfiera! partnership {Is ihe eioi-foi-«*i,jfij cot potation aiso a >U I(r.)t3)}lf
| | Limited pariiicrahip | j V<.-:r { ] ny.
( ! Trust [ } Ojhcr «ptease specify t
2. ?or U:^;-jj eniilii::;, the siaic (0: foresee; country) of iw-orpoiaison Ot urnnni/.atiott. if applicable:
Pot legal entities ««i organ in Use Stole- of Illinois; I las the orgnrteation re&iascred io tin J/i:;Sijie;« in the Stale of Illinois as a foreign entity?
WYts" (f No IJN/A
»». IP THE DISCLOSING PARTY ISA IJiC-AL CNTfTY.
I. List below ti>e full x_>on_ _od littasof alt executive nfftccis and ol! director*, of the entity. NOTE: l"or not-fnr«pjofis corporations, also list. below all members, if any4 u'IikJi arc IctjaJ entities. If il>cro _c ao such nocniben;, write "no members." For trusts, estates mothe? similar cntiiics. list fec!ow the Icjjal ntfclKiWerts).
ff the entity :s o gcsr.'ral partnership, limited partnership, limited liability co'snpaiiy, limited liability pannershjp or joint vwnurc. list below the name ana title ofeach _.«:ncrcl jartpcr. lasntsgteii member, manager or any other person or entity that commls the day-to-day ia?rc_g_n?cftt of the Dixelojrin£ Party. NOTE: F-tcb fe;,;_i entity fisted bulow tttusi submit an EDS oiv its Ovr:: behalf.
Naiuc Till-
2. Please provide the following iafomtotiou eos&cruing ceeb person ox entity having a direct oi indirect beneficial interest (including ownership) in excess of 7.5% of iU_ Oiselosinp Psuty. Bxainnlcs of such ao interest melt: lie shares in a corporation, pamtersltta- trjtefO! hi a p:tut:crch?» or joint v«?taa.re.
Past 2 of >S
interest of a mrmb'ix or masartcr «i :: 11mice:: liability company. ...f jn-.r-tes: of a oenerii'i.v.--, «>!'r. tcu'.t.
;i?c Oi olher si;:w!.^: eniiiy it" "on:. i-iate. *N««e." NOTE: Pursuant to Seaioii .1-15-1-OJO of the -VUniicinal Code of Chicap.o ("Murvi-.-:p.!l Code"), the City may teqiotc any sue a addUioi'-a! i.ilf>.iirr>U\io:t f.'uiji .ir.> ipj:iicj!iii which is reasonably intended lo achieve tVii disclose u
v>at: >: Hiisincjis Address Pereeniagc interest ir. lite
Date losing: Paity
't",:cv:>. ,v. >Vi N. « ?«i St., Nmic '.'&».•¦ <.l»cs!:n. " *0«tll »W&
SECTION 11! -¦ Rl/SINKSS HF.LAi tO.NSlHr.S WITH ClTV Kt.ECrfcSj OlT KTAl.S
Hi* she I^tjatiosirtK Party hat! a ''business relationship." as defined in Chapter 7-156 nfihc Municipal Code, with any Cily elected official ir, lite 17. mouth? befon: the Jate this Hi/S js si$;u.\J?
1 ] Yes M N"n
if ye*, please identify helot* the. motets) of such City elected officially'/ and describe such rclaiioRshiefs):
SECTION IV - DISCLOSURE Ob" SUBCONTRACTORS AND OTHER RETAINED PAR TIBS
Tli-.: Oiseiosir.j; Patty inus! disclose !he mime and business address of cacit subcontractor, attorney, lobbyist, accountant, consultant and any oilier person o: entity whotn the i)iacio:::nf; Party has retained or experts to retain in connection with the Matter, as wcil cs the nature of the relationship, and the total amount ofthe Tecs paid or estimated to he paid. The Disclosing Partynot required to dteciotic employees who ore paid solely through the Disclosing Party's regular payroll.
"Lobbyist"* means any person nr entity who tiwlcnabcj: to influence any lc>:istaitvc ot administrative action on behalf of any person or entity other than: (1) a nos-l'u::.profit entity, ore ao tMpatg basis, or (2) himself, "Lobbyist" also mcatw any person or entity any pars uf wltottt: duties as m employee of another includes undertaking to tatlvcace any legislative or ndmutkttativc action.
if the Disciosttti; Party is uncertain whether a disclosure is required under ibis Section, the Disclosing Party rntsst either ask the Cily whether disclosure i; required or mute the disclosure,
Case 5 of :. 1
Name (indicate whcihc: HufineiW. tciii:u-i! or anticipated Address 10 he .cvair.-.'il)
Relationship io nivr.'nsjr.j, Part;.' (*iibccni!::ictnr. aUuraev, iobbywt. f ie.)
Fees (i.uhc.atc whether paid us asliaiatcd.i NOTE: *"hoa/:y rase" or "Lb-d." is. r,{.-: s.'i :ice::p:ab!c I Cjiponsc.
{Add sheets if necessary)
pfj Chert; here if" the Disclosing Party bsts noi retained, nut expects io rets in. t-i:y sucb pcrso:?:: or cathiei. SECTION V - CERTIFICATIONS
A. COl;RT-OR»l;RtiO CHED SUPPORTCOMPLIANCE
Under Municipal Code Section 1 >. substantial owners of business crukic:; that contract e.-t'.h
ihe City mitsi remain in compli&isce with their child sopfiiin obiifiotaitM !.hrou<.'li«ui the contract's terra-ting say personwhit directly Of indirectly own? 10% or more ofthe Disclosing Parly boco declared in orrcaiajje on any child support obli&attoo.fi by r.rty Illinois court, of etitnpetciii ;urir.diet.K>ii'.'
[ 1 Yen (x' ^° f I No psr^n dixesii* atiadiiecay-owiuJJyy.-«>r-mo«of-ih* - -
Disclosing Party.
tf "Yes," has tbe person cmstcd into a court-approved agreement F«» payment of a'.i svpport »>vcd and is the person in compliance with £fjdt agiecKient?
S1 Yes (. ] No
It. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23. Ankle I ("Article l">^vLkb the Applicant should consult fox defined leims (&.£-» "doing business") and Ic-gal requirements), - Oisclosting Party submiitjog ibis EDS is the Applicant end is doing business with the City, then toe J>isclo:tin$ Pnfty certifies as follows: (i) nctAer the Applicant nor any cojilrolliiijt person is currently indicted or cha.-jjed with, or has- admitted guilt of, or has.' ever been convicted of, or placed under supervision for. any criminal offense bivoivint; actual, attempted, or conspiracy io comntii h-ibwy. theft, fraud, farmery, perjury, dishonesty or dcocit against an officer or employes of Use- City 07 ct>y s'tsiorngcncy: and lb* Applicant tiadeistaad-s and acknowledges that compliance with Article I is a continuing roijuircnicnt For doing business mth the City. NOTE; If Article 1 applies to tbe Applicant, the pr.nniiu-cai. iomplt2:tce titncfTDuic isi Article i supersedes some Gvc-year compliant*; liracftusnes in certifications? and'3 befow.
Pays 4 of 13
r. She D.-.:.i>".iS)!is: }4:. '\i and. >• :hr OiM.;.»:ii^ :'.::;> iN a lejt.Vr entity, ai: of ihn:;.-. S'.v.in o: entities tdctti-.fjcd in Kcctiun il.Fs.i of ifcts HDS.
u :ttc tin! p'e!-::jilly tieisamcd. siwpcitded. ;'-io;k«:;! Ui: debi: "Jen:, declared laeJt.iiibie or kuicalajiiy CA.c.li:deJ limn any irrinsaflcons by any federal, sla'c Of Kk'mI utiil of ui.'vctrituei'.l,
b. haw: no;, within a live-year period preceding tin: d-tte of this KDS, H;vn coavivivd of 2 rnigiaa! offense. ;'.'i;-.id:;,i:.d guilty, or fittd a civil judgment tvoilcro-u gainst them in connection v,-%.' receiving stolen pro-pcrly;
e. aie not presently indicted fur. or ciiminidiy oi civilly cliary.cd by. a jjovernmsntal entity ('.'cd'cial. state or local I with committing any ofthe offenses set forta tit clause B.?b. of ibis Section V;
have not, v/itlii:! a five-year period pivectiing live. have not, within a five •year period pieced! itg ihe dale of Ih.is KDS. been convicted, adjudged j'.titlty, or tumid liable in a civil proeectfitit',, or in any criminal oi civil .jcliun, including actions concernim; environmental violations, riiMitatcd by inc City or by the federal government, any State, or any oihct er.il of local government.
.». 'Hie ccrt:J'iralionx in subparts 3, 4 nod 5 cnoccfn:
* lite Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor twed by die Disclosing Parly in connection with the Mailer, including but not limited to nil pontons oc legal entities disclosed under Section IV. "Disclosure of Subcontractors and Oilier Reiaiired Pnnies"):
any * Affiliasod' Kniily* (mcanine. a person o,i eottty thai, directly or indirectly; controls the Disclosing Party, tit controlled by the Disclosing Party, us is, with the Disclosing Pany. tinder common control of another person or entity, Indicia of control include, crthoui limiiaiion: interlock rnj> mau::i>etncKl ot ownership; identity of iiiicr\»:i£ among family members, snared facilities and equipment; common ?tsc of employees: or organization of a business entity foilov/ing the ineligibility of a business entity to do busiucs:; with federal or sta:e or local government, inclndb:^ the Cily, using i-iibsiatiiially ibcsome management, ownership, or principal* as the ineligible eotiiy): with tespcci to Coutisctors. ihe tcnii Affiliated Entity means a person or eni.tiy ilv.it directly ot indirec tly controls the Contractor, is controlled by «, or. e/iih tbc Contractor, is under common control of another person or entity:
any tesponstbt:: official of ihe Disclosing J'any, any Contractor or any Affiliated fanny or any other offteial. ag.eot or employes ofthe Disclosing Party, any Coniractorc-r any Affil«atcd Knhiy. acting pursuant to the direction or authorization of a responsible official ofthe Disc lit-.; ins Party, say (.¦.njitrseior or any Affiliated l-intily (ccillceltv-eK- "Ajjcn:s"'i.
PiweSof 13
Nciiii;:: the .Disc loamy, Party, i;.ot a»y Ctociracioi. ru»: :vny Affiliated Utility of either ihe Diseiosiit;-. I'uny or nny Conireetor rii>r any Agents havr., during inc five years before the. Jolt tlits liOS is signed, ot. with respect '-¦•> ' Contuse;?;, an Affiliated Fin? by. of a»t Affiliated Entity of a Cotwaeti.r durtitp. the fi\i- ve-ars bct\'::: :i:f dale of >t;er. Contractor's or Affi&itcd tensity's contract enjiagcnienr i:i connection vUb thr
Matter
biibcd Or attempted to bt'ifce. or been convicted Or adjudged puiliy of bribery r.r aUctnptiiii; :o bribe. » public officer or employee of the City, lbs Slate of (lli:uv,rj. or any agency of lit'.: teOeaa! .•jovctnment ot of arty siate or local government ia the United Settles of Akkts-.:: :;t thai offie .:-'$ o: employee's official cap»r,r,y:
agreed or colluded with other bidders o. prospective bidders, or beta a party to any such agreement, oi been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of frccdar.i of eotape.fitioa by agrccineAt to bid a fused price of
otberv-isc; or
made an admission of soch ctmdtrcu described in or b. above that ii a matict of record, bin have not been prosccuced for such conduct: o:
violated the provisions ofMwiiicrpal Code Section 3-92-610 (Living Wuyr. Ordinance).
Neither the D:;a:losi«g Party, A ffiJiatcd Bmiiy or Contractor, or «•»>• of their employees, oflrciabt, ti gen is or partners, is barred from contracting with any uait of state or local government as a resttli of engaging in or being cotivictcd of(l) bid-rigging in violation of 720 ILCS 5-/j_3K-a; ibJgssfffiiB&in
...violation <•« '/20-!lyCS 5.^7»-c->: orfJ) any jtlmilSr'oiTciist:oT&iry^aie o: at'the United Slates of America that contains die same elemci:i.s z$ the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Jintity is listed «» soy ofi.hu fflliowiag lisis maintained by the Office of Foreign Assets Coouol of the U.S. Department ofthe Tivastiry or the Bureau of Industry and Security of On: U.K. Department of Commerce oi {heir success oral: thr. Specially Designated Nationals List, ibt Denied JVntoas Lwi, the Unverified Ust, the liiuliy List, and the Debarred List.
7. If the Disclosing Party is unable to certify to nay ofthe above statement:: in ibis I'nrt B ('I'orifc*? CenificJKtons'k tlte Disclosing Party mast explain below:
It" ;!:« tetters; "NA." the wn:v;i.!r!!ea tiicx *¦ (i¦.- i>:.sJi:::. i'.uly certified li- Site Mlvuv. .•-'-.cent-::;:.
X Tn ihs best i>f ihe Disclosing !';irty's i.!to-.-.'].'r,d\:c after fcasunable hilum,-;, , lite fnlkr-vii5;; i;: a coi')i;>!t:!c list ofaii eurreal employees of lite i)isclo:\.;:i". i'auy who n ere. ^ nny time dittim; ihe ! 2-utontt: (X-fi'.s'.i preceding the execution dat*.: c-f this !;DS. an employee, or elected or appointed official, of the City o< Chicago It f none, indicate v.-sth "N/A" or "'none").
Nono _ _
V. To tit-.: best of the Disclosing Party's knowledge afic: reasonable inquiry, the followinj' is ti complete: lis! of all gifts that the Disclosing Party h food or drink provided in the cou;.«: of officii; City business and having a rcirii! value of lest: iban $20 per recipient (if none, indicate with "N/A" or "none"). As to ,\ny gill lisicxl helstw. please also Yv.-a the Dame of the City cccioivni.
iiuns " ~ " "" *" 7"7' ' ' _'7.".'
<--•- CKRTtRC ATION OF STATUS AS FINANCIAL SNSTiTUTJOiV
The Disclosing Pany certifies ihat the Disclosing Party (check one)
J ] is 00 »s not
a TtaanciaJ institution* as defined in Section 2-J2-455(b) ofthe Municipal Code,
If the Disclosing Party IS a financial institution, then, the Disclosing Tarty pledges:
"We. arc not nod will not become a predatory lender as defined in Chapter 2-32 ofthe Mtioieiptd Code. We further pledge thai none ofour affiliates is. ami none of them will become, a prcdatu.-y lender as defined in Chapter 2-J2 ofthe Municipal Code. We understand ibat becoming fl predatory lender or becoming an affiliate of a predatory tender may result in the loss ofthe privilege of doing business with ihe City."
If the- Disclosing Party is unnbte to make this pledge because is or nrfy of its affiliates (lis defined in Section 2-32-155(b) of the Municipal Code) is a predatory leader within the meaning of Chapter 2'\2 of the Municipal Code, explain here (attach additional pnp.es if necessary):
;,.-ijw7o?' i t
: :" :.!;<. k;:ic ¦-. "\ ." \h-; i¦:M _i --'.-.ll-; :H:: !iVi jh;:n- i- v, :ii
s --:u'•. vU ;. r---.-. t'; :.!'-.e ;'::r:v .•.r. J\1!•a •.; . .
f>. <".!-. iiTI.-iCATIO.N K ! t i A i< i >! \'\ I i V \ i-K ;-S"i «>; CiTY m JNi Y!;Ss
A " y vvur.iv .->. ;e j!. ar. <.:rlliiCvi Sr. C!j:i;>Lt / -1 ?!> ;:'|c; ML.-ia:n.V Co;! .- |- i- i!:.:
i*:iO-. w:;:;,: usk; in .^r:ci. his ot ;t-.'" n. o a ante uf ia ihe name -of any u'.iivt- putsot i ft entity i» t|ic Sk;j:i.::-,'V
! I Vci •<] N\(
NOTE: !t you ehecfecd 'Ye-." »o heta J). Iproceed ;>< itc»ru> I).?., soil I) < ti" y»u cfc-i-ckud "W io UcrsiD.l., prose:: n it» Pert h.
2. i.Jf.>lcy-jf .-cohi pursuant fo a procc*- of eontpeti-ivc bitiiii:)^. or other* tic ae-raitioJ, no C«ty ciccl^d pft'c:;:: ii- enipU-'yev fihuY. havtr fii,-aiti:i:!! >;f£i.-iv.-: rr> hli n: her o-vii n::;iv^ :i: ll:-:: i.iaiat-' of J;ty other ::.:•<<>" or entity V) tire purchase of ::ny pioperty tha; ii) bcJoui-s U< tK- Oty, or |i;i is s<:!;| for us»:es or :iii-::;:.:i«:nt;s. Ot is sold by v stlue of'-egal p!iv;c-S -'.V the -:i. uf U:v C'tv tei'l'.ivr'v.ety. "City rrepvrtv Sale"). CtHnpcfrSafius for prvtfe-ny taken pursti;<:i{ t-.i the Otj'sri-itocti? darvihi puv.v:-does no: constitute a t'ht;.ni !.-¦! intercs! within dn; .'j>^.-;i.iini- ••frii., I'_r: f.
:)rr< the Man;:/ im-nive a City Property Sals''
f ) Vcs f j N'o
}. tf you fhetkut! "Yc%" to ttetn £>.! provide the names and busific:.;. addresses of lb',- C»sy offtcirifi or cmp'oyecs hra iiiy, sttcb iiiieiv.i :;i:d identify the tmsirre of Mich iotciesf
Ntwnc Uus'uicte; Address Naturo of iyierivci
¦\ The l.)is.:lost»p, P;jry furtlies ee:tifi« that sjo prohilmcd flsai-.'.-tt'.s intccta -.n the Master '.viii be arquiiO" hyatty City official or employee
K. CERTSFICATSOM KKCARDlNti Si AVfiKY :;p u BUStNK-SS
l''«SC e!;;-<:;. cidtct f or 2. Iv/'ow. I'll'-.- Disclar.ia" Piivy eltv'vkS 2... il't' Diseto-ar.-i. i'-a^y ivuj^t disclose he;0^ o: tn an attachment to this KDS ari infortitMttoR fc^titted i"»y pata.-.r.tph. i-'aibttc \\-
¦,-!j:::p'y iviih tltcs'.- disclosure :ixi;:;:i;mcn:s may make Sfij '.'.n.'Uac! entered inin with ihf Cilv in Connection With ihe Mailer voidjt:Je hy ihr f'i;y.
X !. The Oisciosins; Party verities th::t the Oiselosmr :l.irtv has scatched any and ali teoirds o:" the !>:;cUwini.\ Patty and ony and ail pr.wc.SSoi entities regarding record? ._< fin vc«: turpi* or pioft::. from slavery n; slaveholder insurance policies during the !;lav«ry r.r.i (including uu.uir.ncc p«1ici«> issued to slaveholders that provided cover^e for damage lo o; injury ft: death of their slaves), ami the Disclosing. Party has found »n such record.-
-• rfK' Disclosing Party verifies thai, as a result of conducting, the search in step i ahovc. tlte
Disclosing Party h.:s found records of irivcs-iacnl.T or profits fiwris slavery or slaveholder insurance W)it;:it;5. Tlte OiscloKing Pai.y vsrillcs thai the follow ins eitrailihtics full d;.^Dn?;;rc of all KuCh record*-, including the names of ony nod all staves ot slaveholders deceit bed in those iccords:
.SECTION VI - CERTlr'lCATIONS FOK KKDERAI.LY FUNDED iWATTfiRS
NOTK: If the Mailer ft federally funded, complete lht.i Section Vi. If the Matter i» not fwierntiy fended, proceed to Section V|}. l-or purpose;: of this Section V!. ta« credits allocated by the City and proceeds of deb: obligation.-; of the City a.c not federal funding
A. CERTIFICATION' REGARDING LOBBYING
i List below the names of all persons or entities registered under the federal Lobbying .Disclosure Act of 1995 who have made tabbying contact!; oa 'r.ebnlf of the Di.Tc.ostn;. Party with respect to the Matter: (Add sheets if neceii-saryl:
(If 1:0 explanation appears or begins on ihe tines above, or if the kuci:! 'NA' ot if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that KG person* or entities registered under «3ie tabbying .Disclosure Act of 1
T,,e disclosing Party has not spent and will not cxpaul any federally appropriated funds 10 pay any person or entity listed in Paragraph A.l. above fm His or her lobbying activities ot to pay any person or cDiity to influence or attempt to influence an officer or employee of any agency, as defused hy applicable federal la w. 3 memher of Congress, in officer or employee of Congress, or .id employee of 5 member of Congress, is connection with tbc award oftiay federally funded contract* malting any federally funded p.ti4i«.oi loan, catering into any coopcra'.i-. v. ;-y.rcc merit, or:« fa^vof I.)
.>. The Disctacn* Pasty -.vsl! submit ass updated ccittfic.-itioa at tlx: cr.tf <:i ct--.-!: calcudai Owaite: tn which there oect.trj any event ;h:K i:;::k:rt;illy 3iTe>:-is .'he accuracy ofthe siatciae.v.s :i;td infontettio'; set forth i.'t partitjraphs A.!. a:ui A.2. a hove.
4. The Disclosing Party cei'tif:e* thai either. (it a is noi an wganiwtiioti described in section
501(e)(4) ot" the Interna} Revenue Ode of 19S6: or Iiii:: an organixadoa Je- -:;!:rd in section
50jfc),'*} ofthe .:HO.fJ.- Revenue 0>r;; of I Vtfo h:tt he.:: ;::>t cnftirgcd and wr'! not C:::;a«;« la '{xdihynw:
Activities".
5. ii';bc Disclosing fatty b: the Applicant, the Discl'-ii-int; Party frtust obtain eertifieritints ciiust in
foiTn and substance to paragraphs A.l. thtouyjo A.4. above front ail subcootrsctort; before it awards any
subcontract and .he Otsclosin;', Party must waiotaia all such subcontractor;' certifications for the
duration ofthe Matter and most taaltc rttch ccrtitkaiion- promptly .--vailsble so th« City opoti rcrptcM.
CI i RT IFIC A T, O N REGARDING i-OUAL EMPl-OVhSE'NT OPPORTUNITY
If Use Matter is federally funded, federal regulations require the Applicant and oil sitoposed subcontractors to .vt.-brn.it the following ttifo.-rnnt.iof ! wiia their bids oi in writing at the ovists o?" negotiations.
Is lite Disclosing I'iuly the Applicam?
—I-Hfcs- fTKb "
If "Yes." atiswsi the three questions below;
t. Have you developed and do you have on file a Omit a'; ive action j'nogrntns piirtjtiar.it lo applicable
fedcrai regulations? (See 41 CFK Port 60-2.)
I } Y I ) Nr.
Have you filed with the Joint Reporting ConvQit'lfcc. the Director of the Office of Federal .Contort Compliance Programs, or the Equal Employment Opportunity Commission all reports, due under tht applicable filing ceqiiiremccus?
? J Yes " \ J No
Have yon participated in any previous contracts orsubc-otstrscis subject to the equal opportunity cEause?
f f Yes U No
If you checked "h-o" Jo question I. or 2. above, plttasc pstvtdr an eA.p!aiia'inri;
Pag; IU of 13
si-:t:TiO:\! vii - a<:kno\vij?i)<:&iI>t.s\ c.ontuact incokporation. COM i'ClANCC. PENALTIES. DISCLOSURE
The Disclosing Party endetifands; arid atp-oes that.
A. The: certification-;. d'Sclosuicj:, and act;nowIcdgtncntx r.i-stained tn '.jji:-: J-DS will become parr ol uny contract O: iv!!;-.• r .-.!-.i'cci:t«a'. between the Applicant and die C:ly ir, connection with the hiauc:. wl:e;r.?r ffroetuvnncnt. City Assistance, n? other Cily action, and are material inducctiseats 10 ibe City':; execution ui' any contract 1?. The City's Ciovemmental rubies and Campaign Financing Ordinances Chapjc-rx 2-156 and 2-16-1 or the WtitsfcipL-! <.'ode. impose certain duties and obligations ot: persons oi casiices sockhii; City contracts, work, business, or transactions. The fori text of these ordinances and a training program is available on line at www.ciivofchicayo.oTfti^lhtcy , and may also be obtained from tin: City's board of tilhies, 74CI \.
Sedgwick St Suite 500. Chiea.t-o, JI, 60610. (.11 2) 74d-9660. The Disclosing Party must comply fully with the applicable ordinances.
!f iii:: City dclerwtncs .'hat any information provide*; i:i tt-s HDS is trdse, iacomplci.e or iriacei;ra;e. any contract ot other agreement in connection with, which it is submitted may be rescinded or be void or voidable, and the < -t;y may pursue any remedies under the cor.tiact or afreet wni (if not rescinded or void), ui taw, or iu equity, including; termircatinf; the Di£e!os:.~£ Party's putiicipctiou in the Matte: and.'o; declititi)!; to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration aitJ an award to she City of treble datttages.
It is die City's policy to make ibis document available to the public oo it:; interna site and/or upon request. Some or all ofthe infotritinfson provided on this EOS sad any attachment;? to Ihis- EDS ttsay be made available to lite public on the Internet, in response to a l-'rcedo:u of Information Act request, or otherwise. By completing and signing this iiDS. the. Disclosing Party waives and releases any possible rights or clatttts » ht'ch it way have against the Cisy in connection with tlte jvatvlic rcltaiJf. of inforttialior, contained in this F.DS and also authorizes «bc City to verify the sccurecy of any information submitted in this fins.
The information provided in this EDS must be kepi current. Its the c ent of chsinjjcs. die Discfoshj-.: Party must supplement ibis BOS up io the tunc the City takes action on the Mailer If the Matter is a contract being handled by the City's Department of Proctocnicni Services. Use Disclosing Party must update thus F.DS a
The Disclosing Pany represents and warrants that:
J*ase 11 «f 15
F.l. The ! >ischioia»i Per iy is ttot delinquent i:i :r.:: payment of a ay Ut.v iitirtiiiiifscrcd by ihe IliiriOiS !)<;ponineiii sif Kcvenuc. m.t are- the QLse.lQ.sini ? Party or iis Affiliated Kntitb;-,-, dclhi'-;i:e;it :rs paying a.-ty fine. fee. Sax or other charge owed lo the Cily. This includes, but nor iiii.iitod So, ail •.¦.aier.e.liaj^iai, -scv.v.i c; forces, license tecs. pai!,i:)s: delect*, property '•ascs '-'< ssilcs taxes*.
1.2 H i);:: Uiscioiia;; Pany is Use Applic-.nl . die .Oii.c taring. Party and sti A!Fd:a:eF.2 If the Diseasing .Party is the Applicant, the Disclosing Pany will obtafn from any eo.nvociots/sabconuroeiois hired or to he hired in coacectior, with *lv.- V> a tier cernftetif.ros equtii ut form and sebstancc to those in l-.t. and t\2. above and will not. wnliom :bc pi-ior wtfttas vocseat of the City, use any such eontraciot/subcutiiracior that does 001 provide such certification* or that the Discin:;jiiP, Party has reason to believe b-'iS not provided 0? cannot provjde tralJvfol certifications.
NOTE: If the Disclosing Party cannot certify a.«c to any of the hews in P. I., F.U. or f.3. above,, an explanatory sir.nj£r»cnl musi be attached to ibis EDS.
ckk pan cation
Voder penalty of perjury, the person signing beiow: (1) o; trrrrojis thai he.'sbc is atiiboir/JBd >o execute this EDS and Appendix A {if applicable) oa behalf of the Disclosing Party, and (2) warrants that all ccitiftccEtoos and sLitmentA contained in thjs KD — ' turt complete as of the date, furnished to the City.
t'A ii.C
(Print or type na:nc of Disclosing Party)
By: 2l ^2zhd-~ - - -
<$U&R here)
Thuirca M. Sc'ii!
(Prim or «ype name of person signing)
Maregiaj SCcmher {Prist or type title of person siyuitig)
Signed and swum to before rat- on fd3.w>„£^r iQ^.-^.^L}.
at Ccot: County. jRnais (state).
CITY Of- CWCACO
economic osstn.osr-Rf.statkxvlw and m-vi davit
UTKM>IX A
i AMII.IAL KKl-ATIONSHIPS WITH Ki.KCI"t\l> CITY OWfdALS AND OKfAKTAIKNT (IKADS
Tlii? Appendix is li> be completed only by (a) I be Applicant, and (l>) any !«;«al entity vfbtcb has st direct mvnersbip interest in ttie Applicant oteeedin" 7.5 percent. (I is not tu 1m; completed l>y any le?;aJ entity ivhich tias only an indirect ownership interest in U:e Applirsn;.
Under Municipal Cade Section 2- i 54-015. the Oiscfosrjog Party mnsi disclose whether such Disclosing Pany ot any "Applieabk- Party" or any Spimsc or Dainciaic Pnittw Lhrnsn-feerrcotly has a "firnilh! rdalkmship"" with ttay elected city official or department head. A "faniilial relit ionsJtip" e».iv-;s ii. as ofthe date, this EDS is stiptcd, the Disc!using Party ur /.ny* Applicable Pany" or any Spouse oi D.nnesue Pattnci thereof is iciaied to the mayor, any alderman,, tlte city clerk, die city trc&sum or any eiiy department head as spntise-or d«n«st:ic partner or a? any of dte following, tvtieibcr by tiHotid or ndoptioa: parent, child, hrctiicr or sister, taint or tmcle. ttsccc or nephew, jpandpnical. snsndchild. fetiier-io-bw. njothei-io-law. soti-iudav.'. dtiuehar-in.to'.v. stepfaiher "Applicable Part/* mesas (1) ail executive officer;; ofthe Diselosa^t Pany listed in SccJioii lLB.I-a., if die Disclosing Party is t) corpu«lirnv, all partners of Ihi; DisdasiriiT I'tirty. ifilie I>i:a;bx;'sis2. Parly is 51 general pc.uncrsLip; aH general partners and Limited partners ofthe Disclosift" Party, if the Disclosing Pony is a limited partiicrship; all Taanasers, managing members cud :ncnibcT5 ofthe Oadosiog Partyv i ft lie Disclosing Pany is a limited liability company: (2) ail principal officers of Ihe DLsihtsfrnt Pany. and (3) tiny person lavitjg. inofc than a 7.5 percent ownership interest tn the Disciu&ng Party. "Ptiacinai offices " nanns .'be president, chief operating uflker, csocuiirc dirscroj. chief *tn.vnci:.»J officer, tn.-r51.1rtT or see-retsiy of u legal entity or any pcreon exercising similar aathorily.
Does the Disclo£.in!! Party 01 any "Applicable Party" or any Spam*.-, or Domestic Pstmer tlttfcof currently have a -%i»iiliaJ reiraiossbrp" with 311 elected cityofiiciai or departnrciti Ji-^ad?
f I Yes M No
If yss. plcsc identify below (l}the name -and title of such pfir$os.(2) the naancof the Itf.-yil cathy to wfa'teh wicb pcfsois ^connected; (3) the name ttirf title of inc elected city official «r depgrtmcat head to wttoct yurfi person has a faniifel Tclationv&ip, attd <'U the precise tatinc «f«uch fatsiliai relationship.
P.5C.C i i 0!' 13
CITY OFCfcitCAGO ECONOMIC DISCLOSURE STATEMENT A.:Vi> AFFIDAVIT A ?!'?'.>.'J"
iiUiLD-INC- CODE SCOKPI^ W/fROBLEM LANrJi.Otfi? CERTIFICATION
This Append!* is fg he cottipfcrtctf only by (a) Ifee Applicant* a«d (b) any l«*ai entity witch fens a directo«?n«esbip Ki(&x*i' in the Applicant exttedtnfc. 7.5 {wrevnt fan fOwfteO-it is aot iu bo waijitatet by any »e*»at entity whk-h be.-? on.iy nn indirect otraersbip tarmst in the Appb're.nf.
1. i'\iTi.uu:u ;t>Mwi&jpa? Coic Section 2-550. is the Applicant urarty Owner id=i3iitfed.asa
building code scorffiawor ptuMcni landlord pursuant to Section a-92-4i6 ofihe MuateiiKil
Cose?
f !v'~< |X I No
2. Sf the Applfcasl is :i fes;:i! r;n?i;y publicly traded on any eA'cW-i:, ;;; a.ny officer o-"directitrof
ilv.: Applicant identified asa building endc .scofliaw or problem laadlord-pumisttt in Section
2-M-l 16 oflhe Municipal Code?
f j Yes f | Ni> fXj Not Applicable
3, Jfyes to (l)or(2) above, please idcniii) befcv Che name of lite- pewant or bsjat enMty
i«kn:»fiod as* Vetoing-code soofWew o* pn&ktn landlord ;:n«5 :be address ofthe baiidicg or buildings to wiudh the pertinent code violations apply.
killing our rms afpewdixb coNsrrnm& ackwwubfgmbkt
AND AGREEMENT THAT TijOS APjPEKDUX B IS INCORPORATED BV REFERENCE. INTO, A NO.VSAD2 A PART OF. THE ASSOCIATED EDS. AM? THAT THE REPRESENTATIONS MASK IN lliIS APPENDIX B ARE SVBJ'ECTTOTIIK C'CRTIflCATiON MADE UNDER PMXALTY W PERJURY OK PACE j* OF THE ASSOCIATED EDS.
CITY OF CHICAGO ECO N OMIC 1) ISC 1-OSl.iK K ST A IT. M £ NT AND AFFIDAVIT
SECTION I - GENERAL. INFORMATION
A. Legal name of the Disclosing Party sunn-iiiting this EDS. Include d/b'a/ ii" iippiicabli;: ?6 liasl Roosevelt. I.I.C
Check ONE of (lie following three boxes:
Indicate whether the Disclosing Party submilfi;;g ibis EDS is: (X] the .A^pireatTP Owner OR
2. [ J a legal entity holding a direct or indirect interest in the Applicant. .Stale the legal name ofthe
Applicant in which the Disclosing Party holds art interest: _
OR
3. f J a loyal entity with a rightof control (sec Section II. B.I.) Slate the legal name oHhe entity in
which the Disclosing Party holds a right of control:
H. Business address of the Disclosing Pany: '¦'•"¦-'> K»fec Road
Huvil-jiVd P«rV. 11.61)105
Tclcpltonc: J 12*36-6037 Pax: Email: ^M^t^^n
Name of contact person: Rolando R- Acosta
Federal Employer Identification No. (ifyou have one);
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development for II36 -40 S. Wabash Avc/26 I- Roosevelt Rd.
G. Which Cily agency or department is requesting this E?>S7^ DPD
[f the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification H and Contract £
Pag« i of I .i
SECTION 1! -DISCLOSURE OK OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
| j Person
f ' Publicly registered business corporation
| ] Privately held business corporation
{ 1 Sole proprietorship
[ j General partnership
[ | Limited partnership
{ 1 Trust
|>3 Limited Habiiity company { 1 Limited liability partnership j ] Joint venture [ j Not-for-profit corporriiioti
(Is ihe not-for-profit corporation also a 501(c)(3))?
2. Eor legal entities, the slate (or foreign country) of incorporation or organization, if applicable:
Illinois
3. For legal entities not organized in the Style of Illinois: Has the organization registered to do business in the Stale of Illinois as a fareigtVcutityV
W N/A
B. IF THE DISCLOSING PARTY IS A 'LEGAL ENTITY:
5. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, ifany, which arc legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titlcholdcr(s).
If the entity is a general partnership, Limited partnership, limited liability company, limited liability partnership »r joint venture, list below the name and title of each general partner, managing member, manager or any other pet-son or entity thai controls tftc day-to-day fflanagcmcflt ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an PI)S on its own behalf.
Name Title
Keith <>ilcs Manager
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of tlte Disclosing Party. Examples of Such an interest include shares in a corporation, partnership interest in o partnership or joint venture.
interest of a member or manner in a limited liability company, or interest ol a beneficiary of a trust, cstiitc or other siinilar entity. If none, stale "None." NOTK: Pursuant to Section 2-154-031') ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such addit.iot.iaI information from any applicant, which is reasonably intended to achieve full disclosure.
Name Business Address Percentage- Interest in the
Disclosing Party
Keith (jitcs Revocable 'tht* dated Strpjcnilvr 16. 2008 _ l>5<> Ridge IUkuI, ilrgtifoiv! IVs.!!. WK».>5 50% Christine Skolnik Rirvw.ibk- Triptr dy.td S*:p5cml\.T If?. ?,00X Un". Ridy.o Knrhi Highland P;trfc. IL.O'XGS f>fi\i.
SECTION 111 - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party hud a "business relationship,"' as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the 1?. months before the dale this EDS is signed?
I. \ Yes W No
If yes, please identify below the namc(s) of Such City elected official(s) and describe such relationship(s):
SECTION IV- DISCLOSURE OF SUBCONTRACTORS AN I) OTH ER RETAINED PARTIES
The Disclosing Patty must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or cotity whom the Disclosing Party has retained • or expects to retain tn connection with the Matter, a,< well as the nature of the relationship, and the total amount ofthe fees paid or estimated io be paid. The Disclosing Parly is not requited todisctosc employees who are paid solely through the Disclosing Parly's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative Or administrative action on behalf of any person or entity odier than: (1) a not-for-profit entity, oo an enpaid basis, or (2) himself. "Lobbyist" also means any person or entity any pari of whose d-oties as an employe*? of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under diis Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Paf:.c.U»f 13
Name {indicate whether Business Relationship to Disclosing, Party l-'ces (indicate whether
retained or anticipated Address (subcontractor, attorney. p.ild or estimated.) NOTE:
!n be retained) lobbyist, etc.) "hourly rate" or "t.b.ti." is
not an acceptable response.
(Add sheets if necessary)
j\] Check here if the Disclosing Party has not retained, not expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-4 J5, substantial owners of business entities that contract with the City must remain incompliance with their child supporl'obHgatton$'tlrfdugHbunhc~c^iitrttci,'$ term.
Has any person who directly or iudircctiy owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support objt^
I ] Yes bf} N'O f ] No person directly or indirectly owas 10% Of more of Che
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?
tl Yes (JNo
8. FURTHER CERTIFICATIONS
I. Pursuant to Municipal Code Chapter 1 -23. Article I ("Article J~)(v.'hich the Applicant should consult for defined terms (e.g, udomg business") and lejjsl requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, ihca the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever beet* convicted of. or placed under supervision, for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, (mud. forgery', perjury, dishonesty or dccc.il against an officer or employee, of the City or any sister agency: and (ii) lite Applicant understands and'acknowledges that compliance with Article I is a conlinttine, requirement for doing business with the City. NOTE: 'If Article 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications ?. and 3 below.
2. The Disclosing. Party and. tf the Disclosing Party j.s a legal eiiliiy. all of those persons or entities
identified in Section fl.B.l. of this EDS:
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by .my federal, state or local null of government;
have not. within a five-\ear period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to Obtain, or performing a public (federal, state or focal) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud: embezzlement; theft; forgery; briber.': 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 ihe offenses set forth in clause 13.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default: and
have not, within a five-year period preceding; the date of this EDS, been convicted,, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any slate, or any olher unit of local government.
3. The Certifications in subparts 3, 4 and 5 concern:
«the Disclosing Parry;
* 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 lo do business with federal or stale or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or. with the Contractor, is under common control of another person or entity:
« any responsible official of the Disclosing Party, any Contractor or any A ffiliated 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 (collcctrvcly "Agents").
Neither ihe Disclosing Pany. v.or any Contractor, nor any A liiJi.ncij Eniirv o/'cithcr the Disclosing Pari}' or nny Contractor nor any Agents have, during the five years before the date this EDS is signed, or. with respect lo a Contractor, an Affiliated Entity, or an Affiliated lintiiy of a Contractor during the five years before (he d.itc of such Contractor's or A I'll M.i ted l-ntity's contiact or eiiL-agcmetil in connection with the Matter:
bribed Or attempted to bribe, or been convicted or ad fudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the Stale of Illinois, or any agency of ihe federal government or of any stale or local government in the United States of America, in {hal 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 fic-cdom ofcompetiiion by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have noi been prosecuted for such conduct; or
violated thc provisions' of iMimfcipal Code .Section 2-92-610 (Living Wage Ordinance).
'Neither the Disclosing Party,. Affiliated Entity or Contractor, or any of their employees, officio Jg,_ itgcms-Or. partner's-bamid- fit)m-contnirling"\vifrralify uittFof state or focal government as a result of engaging iu or being convicted of (I) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating iu violation of 720 ILCS 5/G3E-4; or (3) any similar offense of any slate or ofthe United States of America thai contains the same elements as the offense of bid-rigging or bid-rolafi::g.
Neither the Disclosing Party nor any Affiliated Entity is Itsled on any of the fut lowing lists maintained by the Office of Foreign Assets Control ofthe U.S. Department ofthe Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The. Disclosing Party understands and shall comply %vith the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-15<5 (Governmental Ethics) ofthe Municipal Code.
If the Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Pany must explain below:
Pasrefiof 13
If ihe letters "NA." ihe wo id "Noise." or no response appears on the 'incs above. It wiJI be conclusively presumed lhat the Disclosing Pany certified to the above statements.
H. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Parly who were, at any time during the 12-motilh period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthe Cily of Chicago (if none, indicate with "N/A" or "none'1).
None
9. To the besi ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party hr:S given or caused to be givcu, at any time during the • 2-month period preceding the execution date of this KDS. to an employee, or elected or appointed official, ofthe City of Chicago. For purposes of this statement, a "gift" does nut include: (i) anything marie generally available to C ity employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
None
C, CfiRTlFICATJON OF STATUS AS FINANCIAL INSTITUTION
I. The Disclosing Party certifies that the Disclosing Party (check one)
{ | is is not
a "financial institution" as defined in Section ?.-32-455(b) ofthe Municipal Code.
2v ff the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-52 of the Municipal Code. Wc understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the foss ofthe privilege of doing business vrith the City."
If the Disclosing Party is unable lo make this pledge because it or any of its affiliates (as defined in Section 2-32-;155(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (aiiacb additional pages if necessary):
Page 7 of n
Iflhc letters "NA." the word "None." or no resjnm.se appears on the Sines above. r{ will be conclusively presumed thai thu Disclosing Party certified to the above statements.
D. CiiRTil'JCAT/ON k:Xj AR DING INTERKST iN CITY Bl/SfNgSS
Any words or terms '.hat arc defined in Chapter 2-15<> of the Municipal Code have the same meanings when used in this Part I).
In accordance with Section ?.-156-110 of the M imieip.il Code: Does any official or employee ofthe Cily have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
f ) Yes td No
NOTE: If you cheeked "Yes" to Item D.l., proceed to Items D.2. and 0.3. If yon Checked "No" to kern D.L, proceed'to Part fi.
Unless sold pursua_nno 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 olher person or entity in the purchase of any property that (i) belongs 10 the City, or (ii) is sold for taxes or assessments, or (iii) is sojdby virtue of legal projLCss.aUfo^
~*Ofy"Tfo~pcrty'Sale*1}" Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Property Sale?
f 1 Yes {] No
If you checked "Yes"" lo Item D.l provide the names and business addresses ofthe City officials or employees having such iutercst and identify the nature of such ifileiest:
Name Business Address Nature of ttttorcst
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will he acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither 1- or 2. below, if the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to ihis EDS all information required by paragraph 2. Failure to
Page.S of 13
comply wish these disclosure requirements may make any contract entered into wtrli ihe ('. ilv ::: connection with the Matter \oidableby the City.
X 1. The Disclosing Tarty verifies that the Disclosing Pany has searched any and all records of
the Disclosing Party and any and ali 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 Disclusing Party has found no such records.
2. The Disclosing Party verities that, as a icsult of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance polities. The Disclosing Patty verifies that the following cons', it otc:; full disclosure of all such records, including the names" of any and ali slaves or slaveholders described iit those records:
SECTION VI ~ CERTIFICATIONS FOR FEDERALLY FUNDLI) MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the M atter is not federally funded, proceed to Section VII. For purposes of this Section VI . tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party wilh respect to the Mailer: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Parly means thai NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect lo the Matter.)
2. The Disclosing Pany has net 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 ot employee of any agency, ai defined by applicable federal law. a member of Congress, an officer oi employee of Congress, Of an employee of a member of Congress, in connection with ihe award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded contract grant, loan, or cooperative agreement.
Page *> of 13
The Disclosing Party will submit an updated ccilifRaiiot) at the cud of each calendar quarter in which Ihcrc occurs any event that materially a fleets the accuracy of the statements and information SCI forth in paragraphs A.l. and A.,2. above.
The Disclosing Party certilies that either: (i) it is not an organisation described in section 501(c)(iV) of the Internal Revenue Code of i9S6: or (ii) it is nn organisation described in section 501(e)(4) of the Internal Revenue Code of but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is Ihe Applicant, the Disclosing Party must obtain certifications equal in form and substance tn 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 ofthe Matter and must make siich 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" in formation with their bids or in writing at the outset of negotiations.
Is.the DiscIosing-P-ariy-ibc-A-ppliraiit?-
( } Yes f 3 No
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? {Sec 41 CFR Part 60-2.)
f]Ycs I I No
Have you filed with the Joint Reporting. Committee, the Director ofthe Office of Federal Contract Compliance Programs., or the Equal Employment Opportunity Commission ail reports dec under the applicable filiug requirements?
flYcs 11 No
Have yoo participated in any previous contracts oi subcontracts, subject to the equal opportunity clause?
hYes f]No
If you checked "No" to question i. or2. above, please provide an explanation:
SECTION VII -- ACKNOWLEDGMENTS. CONTRACT INCORPORATION. C O M PI IA N CE, PENALTIES. DISCLOSURE
Tho Disclosing Party understands and agrees thai:
A. The certifications, disclosures, and acknowledgments contained hi this EDS will become part of any contract or other agreement between ihe Applicant and the City in connection wilh 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 tn the Matter. The Disclosing Party understands that it must comply with all statutes. Ordinances, and regulations on which this EDS is based.
fi. The City's Govern mental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchjcatio.orp./Ethics . and may also be obtained from the City's Board of Ethics. 740 N.
Sedgwick St., Suite 500. Chicago, 11. 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and tlte City may pursue any remedies tinder 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 Parly to participate in other transactions wilh the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on tLs Internet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom oflnformution Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up io the time the City takes action on the Matter, tf the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Parly must
update this EDS as the contract requires. NOTE: With respect to Matters subject lo Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 7.-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Payc ; I of 13
r.; Tit; l'>ij>clf»i;tt.t Parly w ¦¦¦A «!.:lin.timti> iH-rwr'.rr.cot of Rcverta**. «ur ate ihe- !)i-s-:»*^ir:;i V'jtriv or ivi Atfiliatul F.'j'-luri. c^'it.i^ucns id j*>:>*y>r.*/ any •"•i:c. Sec. MX oi other cb.';rcc ovecit :o the City. This recltf-ic*. bat it o«i '•irnitec id, ul; water cbar-ge*. .uvv. i.-i cfcarr.fvi. liecn*-. f.v;. jr.* turkcl* properly tr.t.-; or .--iir; cr^^S
f-,2 If tbr f>iiCi.i:^T5-: r'^ri;, :? AppSire.ri. like IJ:.v-/o;nr Parry ;uie iii AftViiiictJ I'wsiej witl r.<>:
*iic, r.nr penuit £h«rSt&cnxWiiTtr-a t» n.«r. any i-trri'^ry hy fhc U.S. I.vP.A. oc folcral Kxcludcc!
Panic* l.iii Sy.Mr^r. f'iirIfs.iiawtr.c^b} the S" 5. Gcticrat Srr.icui A JiryiL-jraikiri
J:t ll the I>***-.Waii; ?.:•;> i» ths At>pvun;rii;!fi.'«;^ufccaa*(Ji;.-Ja!:. r.irrrfi o id bs hsi c^S. ~. -tftrit-txlian -a-rsi: rhc- MilliV vc 1::"jcj::r»r
lOWi and vubstAUOC to t::ijic io J i aJxsvc :tad trtli "oi. ".viifctiTis rjsi; prior •¦*>-• mec consort ufjhc
<.'i'.y, vise any scc/i CAir.t;=CL.->r/i!it:cc.ctr.ivri>T thai cr-cs. «ui prv-ivior ivxi ce~vhVc:moa.s or that the Unclosing Party hAj rc-iics t-> bf'jc\c r.3 ; «ul prnvirf ;c or canrot provide rraTalul ccTrificauons.
'NOTI?: If Use Di«cto&3s. Party c^aaai c.ntt'y as is Jjr.y t'fthc ru-tui. » F.I . lr:.2.u: V.y. above, J»*> cvTvl.-.naioty statewrn: •-"ist be afiaricj*!tfci» Iif>S_
{F.RTIKK.ATJON
t friitc-' penalty v»f pirrjiiry, lire persrit.} *Mr*3**aj> hd;v*. f I j *« ^trartis tifj Sc/iae ok iiu;i>05«tf»4 to execute this UDS and Appeal* A {'ucpptfrcbtci an haa25 o: inc D;-.ctoson^ ?an*jv 2x6 *2l vat rants tfcat at) cer:*i7%-;.Ujuos anc stiiBmcnrs wiriimeiS it*, liiir; TiT)H:
MF«Ki*i*-»i-'i,t.l£:
tPrini or type narac of r»«r«(i' siPBin^j (Print or type tiih* ot porsen &l^ato»>
Signed ami s**ora w bcfotc enc or. {dan:;
it C2rr.*v.
¦Jii r>«-i.
OFFICtAL StAv
Notary PuUie - S:aie ct i Ccatrnission Exprr« SSp 5,2017
l 'Otumt.v.i<>a ex,---ir^:
cm OF CHICAGO ECONOMIC DISCLOSURE STATEMFNT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is (o be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any le«al entity which has only an indirect, ownership interest in the Applicant.
Under Municipal Code Section 2-15-1-015, the Disclosing Party must disclose whether such Disclosing Party or any •'Applicable Party" or any Spouse or Domestic Partner therwf currently has a "familial relationship" with uny elected city official or department head. A "familial relationship" exists; if, as ofthe date this EDS is signed, the Disclosing Pany 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 cily department head as spouse or domestic partner or as any of Use following, whether by blotxi or adoption', parent , child, brother or sister, aunt or uncle, niece or nephew, grandparent, gjandchild, iaiher-in-ltiw, mother-in-law, son-in^aw, daughtcr-i;n-la\v, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsistcr or half-brother or half-sister.
"Applicable Party" means (1) all executive officers ofthe Disclosing Patty listed in Section II.H. 1 .a,, if the Disclosing Pany is a corporation; all partners of the Disclosing Party, jTthe Disclosing Party is a general partnership; all general partners and limited partners oflhc Disclosing Pany, 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 ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship"' with an elected city official or department head?
{ ) Yes fX) No
If yes* please identify below (1) the name and f hie of such person. (?.) the name of the legal entity lo whicft such person is connected; (3) the name and title ofthe elected cily official or department bead to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Pav.e 13 of 1?
CITY OF CHICAGO HCONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX R
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CKRTIKl CATION
I his Appt-udvs is to he coinplctcd only by \a\ the. Applicant, ami (l>) any legal entity wbleti hu$;i direct owirersbip int<:rw,t in the. Applicant exceeding 73 percent (an "Owner"). It is not to be complied by any h,-g;il entity which has only an indirect ownership inftirt&Lin the Applicant.
L Pu.-si.iant lo Municipal Code Seta ion 2-154-010. is the App) iwinl or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-v2-?Y« GD*0
_LJY-
If the Applicant is a legal entity publicly traded on anyexdiringc. is aviy officer or director of tlnvAppticant identified as a building code scofflaw or probhxn landlord pursuant to Section 2-92-416 of the Municipal Code?
No ,jxIp!jat-Applicablc— -
If yes to (1) oj (2) above, pkrast identify below the name of ihe person or .legal entity identified a<; a htiilding code scofflaw or problem landlord and the address ofthe building or bondings Jo whieh the pertinent code violations apply.
FILLING Ol FT THIS APPEN DIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF. THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUftjECT TO TOE CERTIFICATION MADE UNDER PENALTY OE PERJURY ON PAGE 12 OFTHE ASSOCI ATED EOS-
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