Office of the City Clerk - Record #: SO2013-5522

This record contains private information, which has been redacted from public viewing.

Record #:

SO2013-5522

Type:

Ordinance

Status:

Passed

Intro date:

7/24/2013

Current Controlling Legislative Body:

Committee on Zoning, Landmarks and Building Standards

Final action:

2/5/2014

Title:

Zoning Reclassification Map No. 3-E at 1149-1167 N State St - App No. 17792

Sponsors:

Misc. Transmittal

Topic:

ZONING RECLASSIFICATIONS - Map No. 3-E

Attachments:

1. O2013-5522.pdf, 2. SO2013-5522.pdf

Date	Journal Page Number	Action By	Action	Result	Action Details	Meeting Details	Captions
2/5/2014	74835	City Council	Passed as Substitute	Pass	Action details	Meeting details	Not available
1/23/2014		Committee on Zoning, Landmarks and Building Standards	Recommended to Pass		Action details	Meeting details	Not available
1/23/2014		Committee on Zoning, Landmarks and Building Standards	Substituted in Committee	Pass	Action details	Meeting details	Not available
9/4/2013		Committee on Zoning, Landmarks and Building Standards	Held in Committee	Pass	Action details	Meeting details	Not available
7/24/2013	57306	City Council	Referred		Action details	Meeting details	Not available

FINAL FOR PUBLICATION

ORDINANCE

BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:

SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the DX-7, Downtown Mixed-Use District symbols as shown on Map 3-E in the area generally bounded by:

East Division Street; the public alley east of and parallel with North State Street; a line 5 feet in length and 102.40 feet south of and parallel with East Division Street; a line 100 feet east of and parallel with North State Street; East Elm Street; and North State Street,

to the designation of a Residential-Business Planned Development, subject to the use and bulk regulations set forth in the Plan of Development attached hereto and made a part hereof.

SECTION 2. This ordinance takes effect after its passage and approval.

Common Address: 1149-1167 North State Street

FINAL FOR PUBLICATION

RESIDENTIAL-BUSINESS PLANNED DEVELOPMENT NO. BULK REGULATIONS AND DATA TABLE

36,044 SF (0.82 Acres)

16,467 SF (0.38 Acres)

19,577 SF (0.44 Acres)

Gross Site Area:

Area to Remain in the Public Right-of-Way:

Net Site Area:

Maximum Floor Area Ratio (FAR): Base FAR:

FAR Bonuses: (Affordable Housing) Maximum Percentage of Land Coverage: Maximum Number of Dwelling Units: Maximum Number of Off-Street Parking Spaces: Minimum Periphery Setbacks: Maximum Building Height: Minumum Number of Off-Street Loading Berths: Maximum Number of Floors:

8.75 7.00 1.75

Per Site Plan 40 Dwelling Units 74

Per Site Plan 335'

1 (10'x25') Berth 24

■e

BULK REGULATIONS AND . ,. . .

nflTfl TflRi F Applicant: Elm State Property LLC

ufliA iadlc Address: 1149-1167 N. State Street

Date Introduced: July 24,2013

Plan Commission: January 16,2014

"FINATFORTUBLi"CATiO^

PLANNED DEVELOPMENT NO.

Plan of Development Statements

The area delineated herein as Planned Development No. ("Planned

Development") consists of approximately 19,577 square feet (0.45 acres) of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Properly") and is under the single designated control of the Applicant, Elm Slate Properly LLC.

The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance, the Property, at the time of application for an amendment, modification or change (administrative, legislative or otherwise) to this Planned Development is made, shall be under single ownership or single designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance.
All applicable official reviews, approvals or permits arc required to be obtained by the Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or alleys or grants of easements or any adjustment of the right-of-way shall require a separate submittal to the Department of Transportation on behalf of the Applicant or its successors, assigns or grantees.

Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Plans.

Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Departments of Planning and Development and Transportation. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of the Department of Transportation.

All work proposed in the public way must be designed and constructed in accordance with the Department of Transportation Construction Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by the Department of Transportation.

This Plan of Development consists of Sixteen Statements; a Bulk Regulations and Data Table; an Existing Zoning Map; a Surrounding Land-Use Plan; a Planned Development Boundary and Property Line Map; Site Plan; A Landscape Plan; A Green Roof Plan; a

Applicant: Elm State Property LLC

Address: 1149-1167 North Slate Street

Date Introduced: July 24, 2013 Plan Commission: January 16, 2014

FINAL FOR PUBLICATION

Plant List; Building Section Plan; and Building Elevations prepared by Solomon Cordwell Buenz dated January 16, 2014.

The following uses are permitted in the area delineated herein as a Planned Development: multi-unit residential; financial services; food and beverage retail sales; office; personal service uses; retail sales; accessory parking; eating and drinking establishments except that Taverns are prohibited; and accessory uses.
On-Premise signs and temporary signs, such as construction and marketing signs, shall be permitted within the Planned Development subject to the review and approval of the Department of Planning and Development. Off-Premise signs are prohibited within the boundary of the Planned Development.
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 purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations Table has been determined using a Net Site Area of 19,577.27 square feet.
Upon review and determination ("Part II Review"), and 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 review associated with the site plan review or Part II reviews are conditional until final Part II approval.
The Applicant shall comply with the Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation and Fleet and Facility Management and Buildings, pursuant to 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 by the Zoning Administrator, pursuant to Section 17-13-0611-A of the Zoning Ordinance, upon written application by the Applicant, its successors and assigns and, if different than the 'Applicant, the legal title holders and any ground lessors.

Applicant: Elm State Property LLC

Address: 1149-1167 North State Street

Date Introduced: July 24, 2013 Plan Commission: January 16, 2014

FINAL FOR PUBLICATION

The Applicant acknowledges that it is in the public interest to design, construct and maintain the project in a manner which promotes, enables and maximizes universal access throughout the Property. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility.
The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. At the time of a hearing before the Chicago Plan Commmission, all developments must be in substantial compliance with the current City of Chicago Sustainable Development Policy set forth by the Department of Planning and Development. Applicant shall achieve basic L.E.E.D. Certification under the Leadership in Energy and Environmental Design ("L.E.E.D.") Green Building Rating System for the proposed high-rise building and provide a minimum of 50% green roof over the net roof area of approximately 4,807 square feet.
Pursuant to Section 17-4-1004-B of the Zoning Ordinance, the Applicant has requested an increase in the floor area ratio for the Property, as set forth in the bonus worksheet

required under Section 17-4-1003-D and attached hereto as Exhibit ("Bonus

Worksheet"). Any developer of a building receiving an affordable housing floor area bonus ("Eligible Building") must either provide on-site affordable housing units or make a cash payment to the city's Affordable Housing Opportunity Fund. The Applicant has elected to make a cash payment in lieu of providing on-site affordable housing units. In accordance with the formulas set forth in Section 17-4-1004-C and the Bonus Worksheet, the Applicant acknowledges and agrees that it must make a cash payment in the amount of $1,178,544.00 ("Cash Payment"). The Applicant must make the required Cash Payment before the issuance of the building permits for the Eligible Building, including, without limitation, excavation or foundation permits, and must comply with all applicable affordable housing standards and requirements in Section 17-4-1004, the terms of which are incorporated herein by this reference.

This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development Ordinance lapse, the Zoning Administrator shall initiate a Zoning Map Amendment to rezone the property to a DX-7, Downtown Mixed-Use District.

Applicant: Elm State Property LLC

Address: 1149-1167 North State Street

Date Introduced: July 24, 2013 Plan Commission: January 16, 2014

Applicant: Address:

EXISTING ZONING MAP

Elm State Property LLC 1149-1167 N. State Street

Date Introduced: July 24,2013 Plan Commission: January 16, 2014

FINAL FQR RUSLICATIQN

RESIDENTIAL

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COMMERCIAL

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PARKING

COMMERCIAL

1 "~ 1 COMME	3CIAL

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E. DIVISION STREET

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RESIDENTIAL

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RESIDENTIAL

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EXISTING 2-STORY COMMERCIAL BRICK BUILDING TO REMAIN

SITE

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RESIDENTIAL
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PARKING

RESIDENTIAL

40'

80'

SURROUNDING LAND USE PLAN

Applicant: Elm State Property LLC

Address: 1149-1167 N. State Street

Date Introduced: July 24,2013

Plan Commission: January 16,2014

CO LL

^E:-Pjyj_^sJ9_N.STREET

129.25'

E. ELM STREET

3.00'

CROSS HATCHED AREA DENOTES EXISTING 10.00' PRIVATE ALLEY SHARED BETWEEN ADJACENT PROPERTY OWNERS

CENTERLINE OF DIVISION STREET

«= CENTERLINE OF ELM STREET

40'

80'

PLANNED DEVELOPMENT BOUNDARY AND PROPERTY LINE

Applicant: Address: Date Introduced: Plan Commission:

Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16,2014

NEW PLANTERS

. EXISTING STREETLIGHT TO BE RCLOCATEO

HEW PARKWAY

PLANTERSt TREES

"W. ELM-

street::

OWE WAY TRAf PC

E. ELM STREET

TWO-WAY TRAFFIC

16'

32'

SITE PLAN

Applicant: Address: Date Introduced: Plan Commission:

Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16, 2014

:v-s\i-t: w-tf MiH kjkscckw ortsn

io'-n* ! ir-r ormvt S'-cT:

E. ELM STREET

UJ UJ

or i-co

ARCHITECTURAL CANOPY AT STREET LEVEL

< oo

16'

LANDSCAPE PLAN

Applicant: Address: Date Introduced: Plan Commission:

Elm State Property LLC 1149-1167 N. State Street July 24, 2013 January 16, 2014

GREEN ROOF . ,. . _C1 _C4 . _a _t ₁₁₀ ° ¹⁶ ³² ^

LANDSCAPE PLAN S'^Cant: ITJ ?^7T\ ,

Address: 1149-1167 N. State Street

Date Introduced: July 24,2013

Plan Commission: January 16,2014

	CODE	BOTANICAL NAME	COMMON NAME	QTY	CAL	HT	SPRD	ROOT	REMARKS
TREES	UCMG	UIMUS CARPINIFOLIA 'MORI ON GLOSSY'	TRIUMPH ELM		r			BiB	SINGLE STRAIGHT TRUNK. SPECIMEN


1FINAL FOR PUBLICATION ORDINANCE BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the DX-7, Downtown Mixed-Use District symbols as shown on Map 3-E in the area generally bounded by: East Division Street; the public alley east of and parallel with North State Street; a line 5 feet in length and 102.40 feet south of and parallel with East Division Street; a line 100 feet east of and parallel with North State Street; East Elm Street; and North State Street, to the designation of a Residential-Business Planned Development, subject to the use and bulk regulations set forth in the Plan of Development attached hereto and made a part hereof. SECTION 2. This ordinance takes effect after its passage and approval. Common Address: 1149-1167 North State Street FINAL FOR PUBLICATION RESIDENTIAL-BUSINESS PLANNED DEVELOPMENT NO. BULK REGULATIONS AND DATA TABLE 36,044 SF (0.82 Acres) 16,467 SF (0.38 Acres) 19,577 SF (0.44 Acres) Gross Site Area: Area to Remain in the Public Right-of-Way: Net Site Area: Maximum Floor Area Ratio (FAR): Base FAR: FAR Bonuses: (Affordable Housing) Maximum Percentage of Land Coverage: Maximum Number of Dwelling Units: Maximum Number of Off-Street Parking Spaces: Minimum Periphery Setbacks: Maximum Building Height: Minumum Number of Off-Street Loading Berths: Maximum Number of Floors: 8.75 7.00 1.75 Per Site Plan 40 Dwelling Units 74 Per Site Plan 335' 1 (10'x25') Berth 24 ■e BULK REGULATIONS AND . ,. . . nflTfl TflRi F Applicant: Elm State Property LLC ufliA iadlc Address: 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16,2014 © 2014 Solomon Cordwell Buenz "FINATFORTUBLi"CATiO^ PLANNED DEVELOPMENT NO. Plan of Development Statements The area delineated herein as Planned Development No. ("Planned Development") consists of approximately 19,577 square feet (0.45 acres) of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Properly") and is under the single designated control of the Applicant, Elm Slate Properly LLC. The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance, the Property, at the time of application for an amendment, modification or change (administrative, legislative or otherwise) to this Planned Development is made, shall be under single ownership or single designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance. All applicable official reviews, approvals or permits arc required to be obtained by the Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or alleys or grants of easements or any adjustment of the right-of-way shall require a separate submittal to the Department of Transportation on behalf of the Applicant or its successors, assigns or grantees. Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Plans. Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Departments of Planning and Development and Transportation. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of the Department of Transportation. All work proposed in the public way must be designed and constructed in accordance with the Department of Transportation Construction Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by the Department of Transportation. This Plan of Development consists of Sixteen Statements; a Bulk Regulations and Data Table; an Existing Zoning Map; a Surrounding Land-Use Plan; a Planned Development Boundary and Property Line Map; Site Plan; A Landscape Plan; A Green Roof Plan; a Applicant: Elm State Property LLC Address: 1149-1167 North Slate Street Date Introduced: July 24, 2013 Plan Commission: January 16, 2014 FINAL FOR PUBLICATION Plant List; Building Section Plan; and Building Elevations prepared by Solomon Cordwell Buenz dated January 16, 2014. The following uses are permitted in the area delineated herein as a Planned Development: multi-unit residential; financial services; food and beverage retail sales; office; personal service uses; retail sales; accessory parking; eating and drinking establishments except that Taverns are prohibited; and accessory uses. On-Premise signs and temporary signs, such as construction and marketing signs, shall be permitted within the Planned Development subject to the review and approval of the Department of Planning and Development. Off-Premise signs are prohibited within the boundary of the Planned Development. 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 purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations Table has been determined using a Net Site Area of 19,577.27 square feet. Upon review and determination ("Part II Review"), and 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 review associated with the site plan review or Part II reviews are conditional until final Part II approval. The Applicant shall comply with the Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation and Fleet and Facility Management and Buildings, pursuant to 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 by the Zoning Administrator, pursuant to Section 17-13-0611-A of the Zoning Ordinance, upon written application by the Applicant, its successors and assigns and, if different than the 'Applicant, the legal title holders and any ground lessors. Applicant: Elm State Property LLC Address: 1149-1167 North State Street Date Introduced: July 24, 2013 Plan Commission: January 16, 2014 FINAL FOR PUBLICATION The Applicant acknowledges that it is in the public interest to design, construct and maintain the project in a manner which promotes, enables and maximizes universal access throughout the Property. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. At the time of a hearing before the Chicago Plan Commmission, all developments must be in substantial compliance with the current City of Chicago Sustainable Development Policy set forth by the Department of Planning and Development. Applicant shall achieve basic L.E.E.D. Certification under the Leadership in Energy and Environmental Design ("L.E.E.D.") Green Building Rating System for the proposed high-rise building and provide a minimum of 50% green roof over the net roof area of approximately 4,807 square feet. Pursuant to Section 17-4-1004-B of the Zoning Ordinance, the Applicant has requested an increase in the floor area ratio for the Property, as set forth in the bonus worksheet required under Section 17-4-1003-D and attached hereto as Exhibit ("Bonus Worksheet"). Any developer of a building receiving an affordable housing floor area bonus ("Eligible Building") must either provide on-site affordable housing units or make a cash payment to the city's Affordable Housing Opportunity Fund. The Applicant has elected to make a cash payment in lieu of providing on-site affordable housing units. In accordance with the formulas set forth in Section 17-4-1004-C and the Bonus Worksheet, the Applicant acknowledges and agrees that it must make a cash payment in the amount of $1,178,544.00 ("Cash Payment"). The Applicant must make the required Cash Payment before the issuance of the building permits for the Eligible Building, including, without limitation, excavation or foundation permits, and must comply with all applicable affordable housing standards and requirements in Section 17-4-1004, the terms of which are incorporated herein by this reference. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development Ordinance lapse, the Zoning Administrator shall initiate a Zoning Map Amendment to rezone the property to a DX-7, Downtown Mixed-Use District. Applicant: Elm State Property LLC Address: 1149-1167 North State Street Date Introduced: July 24, 2013 Plan Commission: January 16, 2014 Applicant: Address: EXISTING ZONING MAP Elm State Property LLC 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16, 2014 © 2014 Solomon Cordwell Buenz FINAL FQR RUSLICATIQN RESIDENTIAL 0 ft COMMERCIAL n COMMERCIAL COMMERCIAL COMMERCIAL < o cc .> 5 O o O O u PARKING COMMERCIAL 1 "~ 1 COMME3CIAL Q to LU CC -uj m □ < E. DIVISION STREET LU LU < o CO o (_> Lr RESIDENTIAL < o cc LU s o < o cc UJ o u RESIDENTIAL E. ELM STREET >- cc < Q O CO z 2 0- O EXISTING 2-STORY COMMERCIAL BRICK BUILDING TO REMAIN SITE I ■A to UJ cc RESIDENTIALRESIDENTIAL [ PARKING PARKING RESIDENTIAL 40' 80' SURROUNDING LAND USE PLAN Applicant: Elm State Property LLC Address: 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16,2014 © 2011 Solomon Cordwell Buenz 2! CO LL o UJ 2 ^E:-Pjyj_^sJ9_N.STREET 129.25' E. ELM STREET 3.00' CROSS HATCHED AREA DENOTES EXISTING 10.00' PRIVATE ALLEY SHARED BETWEEN ADJACENT PROPERTY OWNERS CENTERLINE OF DIVISION STREET «= CENTERLINE OF ELM STREET 40' 80' PLANNED DEVELOPMENT BOUNDARY AND PROPERTY LINE Applicant: Address: Date Introduced: Plan Commission: Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16,2014 © 2014 Solomon Cord welt Buenz \ NEW PLANTERS . EXISTING STREETLIGHT TO BE RCLOCATEO HEW PARKWAY PLANTERSt TREES "W. ELM- street:: OWE WAY TRAf PC E. ELM STREET TWO-WAY TRAFFIC 16' 32' SITE PLAN 4^ © 2014 Solomon Cordwell Buenz Applicant: Address: Date Introduced: Plan Commission: Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16, 2014 :v-s\i-t: w-tf MiH kjkscckw ortsn io'-n* ! ir-r ormvt S'-cT: E. ELM STREET fr UJ UJ or i-co UJ ARCHITECTURAL CANOPY AT STREET LEVEL < oo 16' 32 LANDSCAPE PLAN Applicant: Address: Date Introduced: Plan Commission: Elm State Property LLC 1149-1167 N. State Street July 24, 2013 January 16, 2014 © 2014 Solomon Cordwell Buenz GREEN ROOF . ,. . _C1 _C4 . _a _t ₁₁₀ ° ¹⁶ ³² ^ LANDSCAPE PLAN S'^Cant: ITJ ?^7T\ , Address: 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16,2014 © 2014 Solomon CofdweM Buenz CODEBOTANICAL NAMECOMMON NAMEQTYCALHTSPRDROOTREMARKSTREESUCMGUIMUS CARPINIFOLIA 'MORI ON GLOSSY'TRIUMPH ELMrBiBSINGLE STRAIGHT TRUNK. SPECIMEN « I	JCSG	JUNIPERUS CHINENSIS SEA GREEN	SEA GREEN JUNIPCR	-			2V	S5	4-<!" ON CENTER
	PHYSOCARPUS OPULIFOLIUS "SEWARD"	SUMMER WINE NINEBARK			34"		us	rJT ON CENTER
	RHUS AROMATICA 'GRO-LOW	GRO-LOW SUMAC				24"	Hi	3 -V ON CENTER
	SPIREA X BUMALDA 'GOLOFLAME'	GOLDFLAME SPIREA				24"	H3	3-<r ON CENTER
	TAXUS X MEDIA 'WAFIDIi'	WARDS YEW				30"	esb	3-0" ON CENTER
1FINAL FOR PUBLICATION ORDINANCE BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the DX-7, Downtown Mixed-Use District symbols as shown on Map 3-E in the area generally bounded by: East Division Street; the public alley east of and parallel with North State Street; a line 5 feet in length and 102.40 feet south of and parallel with East Division Street; a line 100 feet east of and parallel with North State Street; East Elm Street; and North State Street, to the designation of a Residential-Business Planned Development, subject to the use and bulk regulations set forth in the Plan of Development attached hereto and made a part hereof. SECTION 2. This ordinance takes effect after its passage and approval. Common Address: 1149-1167 North State Street FINAL FOR PUBLICATION RESIDENTIAL-BUSINESS PLANNED DEVELOPMENT NO. BULK REGULATIONS AND DATA TABLE 36,044 SF (0.82 Acres) 16,467 SF (0.38 Acres) 19,577 SF (0.44 Acres) Gross Site Area: Area to Remain in the Public Right-of-Way: Net Site Area: Maximum Floor Area Ratio (FAR): Base FAR: FAR Bonuses: (Affordable Housing) Maximum Percentage of Land Coverage: Maximum Number of Dwelling Units: Maximum Number of Off-Street Parking Spaces: Minimum Periphery Setbacks: Maximum Building Height: Minumum Number of Off-Street Loading Berths: Maximum Number of Floors: 8.75 7.00 1.75 Per Site Plan 40 Dwelling Units 74 Per Site Plan 335' 1 (10'x25') Berth 24 ■e BULK REGULATIONS AND . ,. . . nflTfl TflRi F Applicant: Elm State Property LLC ufliA iadlc Address: 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16,2014 © 2014 Solomon Cordwell Buenz "FINATFORTUBLi"CATiO^ PLANNED DEVELOPMENT NO. Plan of Development Statements The area delineated herein as Planned Development No. ("Planned Development") consists of approximately 19,577 square feet (0.45 acres) of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Properly") and is under the single designated control of the Applicant, Elm Slate Properly LLC. The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance, the Property, at the time of application for an amendment, modification or change (administrative, legislative or otherwise) to this Planned Development is made, shall be under single ownership or single designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance. All applicable official reviews, approvals or permits arc required to be obtained by the Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or alleys or grants of easements or any adjustment of the right-of-way shall require a separate submittal to the Department of Transportation on behalf of the Applicant or its successors, assigns or grantees. Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Plans. Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Departments of Planning and Development and Transportation. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of the Department of Transportation. All work proposed in the public way must be designed and constructed in accordance with the Department of Transportation Construction Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by the Department of Transportation. This Plan of Development consists of Sixteen Statements; a Bulk Regulations and Data Table; an Existing Zoning Map; a Surrounding Land-Use Plan; a Planned Development Boundary and Property Line Map; Site Plan; A Landscape Plan; A Green Roof Plan; a Applicant: Elm State Property LLC Address: 1149-1167 North Slate Street Date Introduced: July 24, 2013 Plan Commission: January 16, 2014 FINAL FOR PUBLICATION Plant List; Building Section Plan; and Building Elevations prepared by Solomon Cordwell Buenz dated January 16, 2014. The following uses are permitted in the area delineated herein as a Planned Development: multi-unit residential; financial services; food and beverage retail sales; office; personal service uses; retail sales; accessory parking; eating and drinking establishments except that Taverns are prohibited; and accessory uses. On-Premise signs and temporary signs, such as construction and marketing signs, shall be permitted within the Planned Development subject to the review and approval of the Department of Planning and Development. Off-Premise signs are prohibited within the boundary of the Planned Development. 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 purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations Table has been determined using a Net Site Area of 19,577.27 square feet. Upon review and determination ("Part II Review"), and 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 review associated with the site plan review or Part II reviews are conditional until final Part II approval. The Applicant shall comply with the Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation and Fleet and Facility Management and Buildings, pursuant to 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 by the Zoning Administrator, pursuant to Section 17-13-0611-A of the Zoning Ordinance, upon written application by the Applicant, its successors and assigns and, if different than the 'Applicant, the legal title holders and any ground lessors. Applicant: Elm State Property LLC Address: 1149-1167 North State Street Date Introduced: July 24, 2013 Plan Commission: January 16, 2014 FINAL FOR PUBLICATION The Applicant acknowledges that it is in the public interest to design, construct and maintain the project in a manner which promotes, enables and maximizes universal access throughout the Property. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. At the time of a hearing before the Chicago Plan Commmission, all developments must be in substantial compliance with the current City of Chicago Sustainable Development Policy set forth by the Department of Planning and Development. Applicant shall achieve basic L.E.E.D. Certification under the Leadership in Energy and Environmental Design ("L.E.E.D.") Green Building Rating System for the proposed high-rise building and provide a minimum of 50% green roof over the net roof area of approximately 4,807 square feet. Pursuant to Section 17-4-1004-B of the Zoning Ordinance, the Applicant has requested an increase in the floor area ratio for the Property, as set forth in the bonus worksheet required under Section 17-4-1003-D and attached hereto as Exhibit ("Bonus Worksheet"). Any developer of a building receiving an affordable housing floor area bonus ("Eligible Building") must either provide on-site affordable housing units or make a cash payment to the city's Affordable Housing Opportunity Fund. The Applicant has elected to make a cash payment in lieu of providing on-site affordable housing units. In accordance with the formulas set forth in Section 17-4-1004-C and the Bonus Worksheet, the Applicant acknowledges and agrees that it must make a cash payment in the amount of $1,178,544.00 ("Cash Payment"). The Applicant must make the required Cash Payment before the issuance of the building permits for the Eligible Building, including, without limitation, excavation or foundation permits, and must comply with all applicable affordable housing standards and requirements in Section 17-4-1004, the terms of which are incorporated herein by this reference. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development Ordinance lapse, the Zoning Administrator shall initiate a Zoning Map Amendment to rezone the property to a DX-7, Downtown Mixed-Use District. Applicant: Elm State Property LLC Address: 1149-1167 North State Street Date Introduced: July 24, 2013 Plan Commission: January 16, 2014 Applicant: Address: EXISTING ZONING MAP Elm State Property LLC 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16, 2014 © 2014 Solomon Cordwell Buenz FINAL FQR RUSLICATIQN RESIDENTIAL 0 ft COMMERCIAL n COMMERCIAL COMMERCIAL COMMERCIAL < o cc .> 5 O o O O u PARKING COMMERCIAL 1 "~ 1 COMME3CIAL Q to LU CC -uj m □ < E. DIVISION STREET LU LU < o CO o (_> Lr RESIDENTIAL < o cc LU s o < o cc UJ o u RESIDENTIAL E. ELM STREET >- cc < Q O CO z 2 0- O EXISTING 2-STORY COMMERCIAL BRICK BUILDING TO REMAIN SITE I ■A to UJ cc RESIDENTIALRESIDENTIAL [ PARKING PARKING RESIDENTIAL 40' 80' SURROUNDING LAND USE PLAN Applicant: Elm State Property LLC Address: 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16,2014 © 2011 Solomon Cordwell Buenz 2! CO LL o UJ 2 ^E:-Pjyj_^sJ9_N.STREET 129.25' E. ELM STREET 3.00' CROSS HATCHED AREA DENOTES EXISTING 10.00' PRIVATE ALLEY SHARED BETWEEN ADJACENT PROPERTY OWNERS CENTERLINE OF DIVISION STREET «= CENTERLINE OF ELM STREET 40' 80' PLANNED DEVELOPMENT BOUNDARY AND PROPERTY LINE Applicant: Address: Date Introduced: Plan Commission: Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16,2014 © 2014 Solomon Cord welt Buenz \ NEW PLANTERS . EXISTING STREETLIGHT TO BE RCLOCATEO HEW PARKWAY PLANTERSt TREES "W. ELM- street:: OWE WAY TRAf PC E. ELM STREET TWO-WAY TRAFFIC 16' 32' SITE PLAN 4^ © 2014 Solomon Cordwell Buenz Applicant: Address: Date Introduced: Plan Commission: Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16, 2014 :v-s\i-t: w-tf MiH kjkscckw ortsn io'-n* ! ir-r ormvt S'-cT: E. ELM STREET fr UJ UJ or i-co UJ ARCHITECTURAL CANOPY AT STREET LEVEL < oo 16' 32 LANDSCAPE PLAN Applicant: Address: Date Introduced: Plan Commission: Elm State Property LLC 1149-1167 N. State Street July 24, 2013 January 16, 2014 © 2014 Solomon Cordwell Buenz GREEN ROOF . ,. . _C1 _C4 . _a _t ₁₁₀ ° ¹⁶ ³² ^ LANDSCAPE PLAN S'^Cant: ITJ ?^7T\ , Address: 1149-1167 N. State Street Date Introduced: July 24,2013 Plan Commission: January 16,2014 © 2014 Solomon CofdweM Buenz CODEBOTANICAL NAMECOMMON NAMEQTYCALHTSPRDROOTREMARKSTREESUCMGUIMUS CARPINIFOLIA 'MORI ON GLOSSY'TRIUMPH ELMrBiBSINGLE STRAIGHT TRUNK. SPECIMEN « IJCSGJUNIPERUS CHINENSIS SEA GREENSEA GREEN JUNIPCR-2VS54-<!" ON CENTER POSPHYSOCARPUS OPULIFOLIUS "SEWARD"SUMMER WINE NINEBARK34"usrJT ON CENTER AAGLRHUS AROMATICA 'GRO-LOWGRO-LOW SUMAC24"Hi3 -V ON CENTER SBGSPIREA X BUMALDA 'GOLOFLAME'GOLDFLAME SPIREA24"H33-<r ON CENTER 1MWTAXUS X MEDIA 'WAFIDIi'WARDS YEW30"esb3-0" ON CENTER< cn i> £^ >- Z S3 13	CAKF	CALAMAGROSTIS ACUTIFLORA KARL FORESTER'	KARL FORESTER FEATHER REED GRASS					03	2 -0- ON CENTER
	PANICUM VIRGATUM -SHENANDOAH'	SHENANDOAH REO SWITCH GRASS					m	2'-0- ON CENTER
	PENNISETUM ALOPECUROIDES 'HAMELN'	HAMELN DWARF FOUNTAIN GRASS						r-tr ON CENTER
	EuONYMUS FORTUNEI COLORATUS'	PURPLELEAF WINTERCREEPER					OT	r-0" ON CENTER
	ECHINACEA PURPUREA 'MAGNUS'	MAGNUS PURPLE CONEFLOWCR					Ml	I ' S-ON CENTER
	HEMEROCALLIS SPECIES MIX	DAYLILY					81	1-f ON CENTER
	NEPETA X FAASSENII	CATMINT						l'-6- ON CENTER

PLANT PALETTE

^4niSjg^?r'-''^t'^Wl":-"--''''

^ *OOTBAU I

1HXX TKFE tVHH STRONG CtNTRAL LEADER (DO NOT PRUNE. ITAKL C* WRAP TMU UNLESS DIRECTED TO DO lO BT THE IANUSCAPI AJtCMTECT)

TUE WATCRMG BAG fSEI iPECVCATONl) WIT ALL SAME DAY nt[ R PLANTED. BAG TO REMAIN ON TREE AND RJPT FULL THROUGHOUT THE GROWING SEASON DURING HAL WARRANTY rCKlOO

CROWN C* HOOT BAU FLUSH WITH fPJBH GRADE LEAVING TRUNK HAAE VTSBUTAT Tl* Top C* ROOT BALL

PIMOVI AIL TWINE, HOPL WIRE. BURLAP AND FLA1T.C WRAP FROM TOP HAL/ Of ROOT IALL

t* plant a s>xmo wth a wim basket

AROUND THE ROOT BALL CUT WIRE W FOUR PLACES AND FOLD DOWN r INTO PLANTING HOLE)

r depth organic Mm cm later, after

SETTLEMENT NAt OUrt TER RING OO

not pvace mulch fn contact with Tret Trunk

roughen cdgcs o* planting pit

PLANTING MlXTURl BACXflU. UNEXCAVATCD OR EXITING IOL TAP*> PLANl INC MiXTURf AROUND BASE AND IJMXR ROOT BAIL tO STABILIZE TR£l ROOT BALL ON UNLKCAVATtD OR TAMP1D SOIL

-T) ' .'"".J^L vTT' ■ f. "If j FZiii-

-4._;ii..-4-.-a.L rqLLV^ ■-rO.^-iiJ.f-1 ^-

I I i I

| ROOT BALL J

V=i-0'

SHRUB INSTALLATION DETAIL

SHRUB (OO NOT PRUNE. STAKE. OR WRAP SHRUBS UNLESS 0»CCTfD TO DO SO BT LANDSCAPE ARCHITECT) CROWN OF ROOT BALL FUAH WITH TMSH GRADE LEAVING TRUNK PLARC VTStfftl AT TK TO" C THE ROOT BALL RIMOVt ALL TWINE. ROPL WIRE. BURLAP AND PLASTIC WRAP¹ FROM TOP¹ MAJJf Of ROOT BALL (IF PLANT Q SUPPED WITH A WUU BASKET AROUND THE ROOT BALL CUT WIRE M FOUR PLACES AND POLO DOWN*- into PLANTING HOLE) I- DEPTH ORGANIC MULCH LAYER. A/TtR HTTLEMINT. TO EOGC Cf PLANT NG BED DO NOT PLACE MULCH IN CONTACT WITH SHRUB

FMSH GRADE

PLANTING MIXTURE BACKflLL ROUGHEN EDCCS Of PLANTING PIT TAMP PLAT/T1NG MIXTURE AROUND BASE AND UNDER ROOT BALL TO STABRJZE SHRUB

- UNCXCAVATfD OR CXtinNC ICL

<W1H 1MIOC* GREEN ROOF TRAT ROC* AND WAT LRPROOf 9 JG LATER

TREE INSTALLATION DETAIL

4" DEPTH LIVEROOF GREEN ROOF TRAY Ju*=r-o-

flNPjHCAADC

ORNAMENTAL GRAM / PERENNIALS / GROUNDCOVtR

1' DEPTH ORGANIC NLRCH LAYER. AFTER SETTLEMENT TOTOPDftESS PLANTING BED DO NOT PLACE MULCH IN CONTACT WITH PLANT MATERIAL STEMS

RAGE FINISH GRADE OF PLANTING BID 4" FOR ACCQUATf ORAMACf

Planting mixture set sol depth

CHART

UNOCAVATFD OR EXISTING SOIL

13?

VARIES

SLl PLANT UM FOP. PRCMR SPACING OF PLANT MATERIAL

000

LANDSCAPE AREAS	DEPTH IN INCHES
LAWN AREAS (SODI	12
PLANTING BEDS -PERENNIALS	18 PLANTING MIX
PLANTING BEDS - MEDIUM AND SHALL SHRUBS	18 PLANTING MIX
RAISED PLANTERS	48 PLANTING MIX
SHADE AND ORNAMENTAL TREES	PER TREE INSTALLATION DETAIL

SOIL DEPTH CHART

GROUNDCOVER/PERENNIAL INSTALLATION DETAIL

JV=r-o-

NOTE. THE CONTRACTOR IS TO SUPPLY SOIL FILL MATERIAL TO THE OEPTHS INDICATED ON THE CHART ABOVE.

PLANT LIST

Applicant: Address: Date Introduced: Plan Commission:

Elm State Property LLC 1149-1167 N. State Street July 24, 2013 January 16,2014

OVERALL BUILDING SECTION

Applicant: Address: Date Introduced: Plan Commission:

Elm State Property LLC 1149-1167 N. State Street July 24, 2013 January 16,2014

_v T / BUILDING

40'

SOUTH ELEVATION

Applicant: Address: Date Introduced: Plan Commission:

/ BALCONY WITH GLASS RAILING

- HIGH PERFORMANCE VISION/ SPANDREL GLASS AND METAL WALL SYSTEM

HIGH PERFORMANCE VISION/ SPANDREL GLASS AND METAL WALL SYSTEM

20'

ARCHITECTURAL SCREEN WALL

Elm State Property LLC 1149-1167 N. State Street July 24, 2013 January 16, 2014

_v T / BUILDING

HIGH PERFORMANCE VISION/ SPANDREL GLASS AND METAL WALL SYSTEM

20-

40'

WEST ELEVATION

Applicant: Address: Date Introduced: Plan Commission:

Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16, 2014

^r,NAL-FOR PUBLICATION

> T / BUILDING

HIGH PERFORMANCE VISION/ SPANDREL GLASS AND METAL WALL SYSTEM

BALCONY WITH GLASS RAILING

HIGH PERFORMANCE VISION/ SPANDREL GLASS AND METAL WALL SYSTEM

20'

40'

NORTH ELEVATION

Applicant: Address: Date Introduced: Plan Commission:

Elm State Property LLC 1149-1167 N. State Street July 24, 2013 January 16, 2014

- ARCHITECTURAL SCREEN WALL

7 / RESIDENTIAL

HIGH PERFORMANCE VISION/ SPANDREL GLASS AND METAL WALL SYSTEM

BALCONY WITH GLASS RAILING

HIGH PERFORMANCE VISION/ y SPANDREL GLASS AND METAL WALL SYSTEM

/ - SYNTHETIC STUCCO

^ B / RESIDENTIAL

■ PAINTED ARCHITECTURAL CONCRETE

OUTLINE OF EXISTING BUILDING TO REMAIN

i B / AMENITIES

. T / EXISTING BUILDING 'EL 29 -8" */.

E ELM STREET

Applicant: Address: Date Introduced: Plan Commission:

EAST ELEVATION

Elm State Property LLC 1149-1167 N. State Street July 24,2013 January 16, 2014

^ inn °) -z

CITY OF CHICAGO

APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE

1. "7Wi^iTbSS of the property Applicant is seeking to rezone:

1149-1167 North State Street

CITY Chicago

2. Ward Number that property is located in:

APPLICANT Elm State Property LLC

ADDRESS 540 West Madison Street - #2500

STATE Illinois

ZIP CODE 60661

PHONE 312.5.42.3161

EMAIL dnelson@drw.com

CONTACT PERSON David Nelson

Is the applicant the owner of the Property? YES (1149-59 N. NO

State)

If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application lo proceed.

OWNER Division State Property 1 LLC (owns 1163- 1167 N. State)

ADDRESS 540 West Madison Street - #2500 CITY Chicago

STATE Illinois

ZIP CODE 60661

PHONE 312.542.3161

EMAIL dnelson@drw.com

CONTACT PERSON David Nelson

If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:

ATTORNEY Edward J. Kus / Shefsky & Froelich

ADDRESS 11 I East Wacker Drive - Suite 2800

ZIP CODE 60601

STATE Illinois

FAX 312.275.7586

EMAIL ekus@shefskylaw.com

CITY Chicago PHONE 312.836.4080

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.

DRW-M Investor - 100% owner

On what date did the owner acquire legal title to the subject property? March 2010.
Has the present owner previously rezoned this property? If Yes, when?

Present Zoning District DX-7 Proposed Zoning District Planned Dev.
Lot size in square feet (or dimensions) 19,577 Square Feet
Cun-ent Use of the property Commercial Uses
Reason for rezoning the property The height of (he proposed building exceeds 155' and
requires a planned development.

13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)

A new building will contain 40 dwelling units and 80 on-site accessory parking spaces with approximately 4,200 square feet of ground floor retail space. The proposed building will be approximately 335'tall. An existing 2-story commercial building at 1163-67 N. State will remain.

On May 14"', 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 of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)

YES X NO

12492G5_1

.■-4.

APPLICATION N

CITY OF CHICAGO

AN APPLICATION TO THE CHICAGO PLAN'.COMMISSION LTNDER^ \/ CHICAGO LAKEFRONT PROTECTION O^JDIN'

(This Application Must Be Typewritten)

The Chicago Plan Commission lias provided this Application Form in accordance with SSttjofi. I' ^IJ^o^Jj&rJ of llic Lake Michigan and Chicago Lakefront Protection Ordinance. The Conditions under which ther^nrtsToiis of this Ordinance arc applicable are slated in Section I 94B-5.I of the Ordinance. The process of Plan Commission review and public hearing on each proposal within the Lake Michigan and Chicago Lakefront Protection District will commence with the Applicant's submission to the Chicago Plan Commission of a completed Application Form and the required proof of notice. Strict compliance with Section 1 94B-6.1(c) is required.

The staff of the Department of Planning is available to provide technical assistance to the Applicant, before preparation of his application, during the processing stages, and to review ihe application at submission to the Chicago Plan Commission. Copies of the Ordinance and this Application Form and examples of forms for both notification and proof of notice, are available from the Commissioner of Planning, in Room 1003, Lakefront Unit, City Hall, 121 N. La Salic Street, Chicago, Illinois 60602. Phone 744-6551.

This Application Form consists of Five Parts on 17 pages:

Part One: General Information

Part Two: Character of Proposal

Part Three: Zoning Information

Part Four: Potential Impact of Proposal (2 Sections)

Part Five: Disclosure Forms (6 Sections)

A copy of this Application will be available for public inspection in the office of the Commissioner of Planning, Room 1000, five days prior to the date of which the public hearing on this Application before the Chicago Plan Commission is to commence.

yes no: Type and

Date of receipt in DP'.

In Hldgs.:

-SECTION BELOW FOR OFFICE USF. ONLY-

. ZBA action necessary?

Status.

Dale of Applicant Notice to taxpayers of record. _

Date set for public hearing:

Date on which Plan Commission

published newspaper notice

_ycs.

Disclosure necessary? _

Simultaneous rianned Development

processing yes no

Pievious Application this address?

yes no; number

Zoning map amendment? yes.

no: U

Date of publication of report

of Commissioner of DP:

DISPOSITION

Date forwarded to OIS

DI'W:. Oihei:

DSS

Pk. D.:

Approved

Disapproved

Continued , lo

Date Applicant notified ofdecision_

SITE ADDRESS: 1149-1167 North State Street

GUIDELINES FOR COMPLETING PART ONE OF THE APPLICATION

Pari One of (his Application provides general information to the Plat. Commission for use in preparing its public notices of Ihe proposal set forth in the Application and in preparing its review of that proposal.

The date entered in I. should be the date on which the Application is filed.
The location of the site of the proposal should be given by street address; if there is no address, the location must be described in relation to existing streets, rights-of-way or other fixed points of reference.
The Applicant must state his own name, address and telephone number and the name, address and telephone number of the owner of the subject property. The Applicant must be either the owner of the subject property or his duly authorized agent or representative, and, if the Applicant is an agent or representative, the Applicant must submit proof to the Commission that he is authorized to represent the owner of the subject property.

Whenever the ownership of the subject property is complex - a partnership, corporation, land trust or association - the Applicant shall so indicate. Further, the Commission may require disclosure of all real parties of interest in the subject property.

The description of a proposal should include, at a minimum, types of land uses and space uses, floor area, number of dwelling units and height of proposed structures in feet or stories. Additional concise information may also be included.
Under the provisions of Section 1 94B-6. 1 of the Lake Michigan and Chicago Lakefront Protection Ordinance, the Applicant must submit to the Commission at the lime of filing axi Application a list of the names and last known addresses of the owners of all property on which notice must be served, the method of service employed, the names and addresses of persons so served, and a statement certifying that the Applicant has complied with the noticing provisions of Section 194B-6.1(c) of the Lake Michigan and Chicago Lakefront Protection Ordinance. The Commission will not accept an application unless and until the Applicant furnishes the required list and certificate.
If there arc any other approvals required from other public agencies before the Applicant can proceed with his proposal, they should be listed; except that other City of Chicago licenses and permits may be omitted as items requiring listing herein. If no other approvals are required, enter "NONE" under VI A. Examples of items which should be listed include approval of FHA financing, a U.S. Corps of Engineers permit, Federal Aviation Authority Approval, among others.

PART ONE: GENERAL INFORMATION

Date of Application: July 25, 2013
Address or location of the Site of the Proposal: 1149-1167 North State Street
Information on the Applicant and the Owner

Applicant

1. Name: Elm State Property LLC Phone: 312.542.3161
2. Address: 540 West Madison Street, Suite 2500, Chicago, IL 60661
Owner

1. Name: Elm State Property LLC (1149-59 N. State) and Division State Property LLC (1163-1167 N. State) Phone: 312.542.3161
2. Address: 540 West Madison Street, Suite 2500, Chicago, IL 60661
If the Applicant is not the owner, check here X that proof has been attached to this Application that the Applicant is the duly authorized agent or representative of the owner.
Ifthe ownership of the subject property is complex, the Applicant shall indicate the type of ownership:

1. Land Trust 2. Partnership or Association

3. Corporation 4. X - An Illinois Limited Liability Co.

Brief Description of the Proposal: The Applicant proposes to develop a mixed-use building

on the northeast corner of State & Elm Streets. The building will contain ground floor retail and a maximum of 40 dwelling units and on-site parking. The two-story building at State & Division will remain.

The noticing provisions of Section 194B-6.l(c) have been completed as they apply to the

Applicant: Check here X.

The Applicant must also obtain the following approvals in addition to the approval of the

Plan Commission:

1. Nature of Approval: Planned Development - Application No. 17792 introduced July 24,2013.
Agency: Chicago Plan Commission and City Council
Nature of Approval:

Agency:

Nature of Approval:

Agency:

Address: 1 149-1167 North State Street

GUIDELINES FOR COMPLETING PART TWO OF THE APPLICATION

All graphic materials must be submitted in an 8.5 x 11" format and must be suitable for clear and sharp, black and white reproduction. Each map or diagram should have a scale and a north arrow. Each sheet of graphic material must be labeled with the appropriate figure number. If there are multiple sheets comprising one figure - for example figure 4 - those sheets should be labeled consecutively, for example Figure 4-1, Figure 4-2, etc., and each sheet should contain the address of the site of the proposal in the lower left comer.

For Figure 1, the Applicant should consider the "vicinity of the site" to be at least as extensive as the area for which he is required to give notice plus any intervening streets or other public rights-of-way.

For Figures 3 and 4, the Applicant should consider that "recreation areas" and "recreation space and facilities" include game courts, swimming pools and pool areas, game rooms, exercise rooms, party rooms, community rooms, observation decks and sun decks.

The required narrative statement should describe the features of the proposed development, including size and mix of dwelling units, mix of uses on the site, etc. It should present a basic rationale for the development.

For Figure 6, the Applicant is urged to provide any materials at 8.5" x 1 I" which will facilitate the review of his Application.

PART TWO: CHARACTER OF THE PROPOSAL

This portion of the Application must be completed by attaching the following items, correctly sized and labeled, to the Application:

Figure 1: A Map of the Vicinity of the Site showing Lake Michigan, lakefront parks, preferential streets, schools, parks, major institutions. All streets on this map should be named, and the outline and height on all structures on properties immediately adjacent to the site of the proposal must be shown.
Figure 2: A Map of the Existing Site showing locations and dimensions of lot lines; contour intervals (5-foot); existing structures, walkways, driveways, special features.
Figure 3: The Proposed Site Plan showing locations and dimensions of proposed structures, driveways and walkways; proposed exterior parking areas; proposed exterior open space and recreation areas,
Figure 4: Proposed Floor Plans including the ground floor, a typical floor, any floor witli recreation space or facilities.
Figure 5: An Elevation or Cross-section showing the height and number of stories for all proposed structures.
Narrative: A Statement Describing the Proposed Development

In addition, the Applicant is encouraged to provide additional graphic materials, visual aids; e.g., photographs, renderings, data tables, among others. Any such exhibits shall be labeled Figure 6.

PART THREE: ZONING INFORMATION

The Applicant shall provide the basic data on zoning considerations for the site of the proposal. Calculations may be shown below on this page and on page 8.

I. Is a planned development ordinance or an amendment to an existing planned development required or permitted for the subject site?

X required permitted Building height exceeds 155 feet.

If a planned development approach is required, or if it is permitted and the Applicant chooses to seek a planned development amendment, the Applicant is not required to complete the remainder of Part Three of this Application Form.

Address: 1149-1167 North State Street

II Is Zoning Board of Appeals approval a variation or a special use either necessary or

contemplated in relation to the Applicant's proposal? yes no.

If "yes," please explain the nature of the approval

III. Net Site Area and Existing Zoning District Classification (list that portion of the net site area in each):

District Classification Area

sq. ft.
sq. ft.

D. Total Net Site Area

rv. Dwelling Units

A. Maximum units allowed

Without efficiency units: .
With maximum percent of efficiency units:

B. Proposed number of units

Dwelling units: _
Efficiency Units:
Total Units:

C. Docs the Applicant intend to increase allowable floor area by reducing the number of units constructed below the maximum allowed?

yes no.

If "yes" there will be units fewer than the maximum allowed, and the Floor

Area Ratio for the site will be increased by %.

Address: 1149-1167 North Slate Street

This page for calculations.

Net Site Area: Proposed Building Area: Proposed Floor Area Ratio: Proposed Building Height:

Address: 1149-1 167 North Slate Street

Bulk

A. Base

B. C.

Floor Area Ratio (F.A.R.), without bonuses: .

Proposed F.A.R., include all bonuses: .

List all bonuses used in computing B., above:

Proposed Floor Area: sq. ft.
Percentage of floor area devoted to interior recreation space, meeting rooms, etc.:

Off-street Parking and Loading

Minimum Required Number Proposed

1. Parking Spaces
2. Loading Docks .
Setbacks

Minimum Proposed

A. Front

B. Side

C. Rear

Address: 1149-1167 North State Street

PART FOUR: POTENTIAL IMPACT OF THE PROPOSAL

The Chicago Plan Commission requires that the Applicant address the Fourteen Basic Policies of the Lakefront Plan of Chicago and the Thirteen Purposes of the Lake Michigan and Chicago Lakefront Protection Ordinance, as listed below, in a written statement to the Commission attached to this Application Form and labeled Part Four. The statement should indicate which policies or purposes are or are not applicable to the Applicant's proposal, and, for those policies and purposes which are applicable, the statements should discuss the potential impact of the proposal.

1. Fourteen Basic Policies

Complete the publicly owned and locally controlled park system along the entire Chicago lakefront.

RESPONSE: This policy is inapplicable as the proposed development does not involve publicly owned land or the park system along the Chicago lakefront. It is in the Private Use Zone.

Maintain and enhance the predominantly landscaped, spacious and continuous character of (he lake shore parks.

RESPONSE: This policy is inapplicable as the proposed development is not adjacent to the parks, and thus, docs not affect the character of the lake shore parks.

Continue to improve the water quality and ecological balance of Lake Michigan.

RESPONSE: The proposed development has no direct impact upon the water quality and ecological balance of Lake Michigan. All infrastructure and building development will conform to all applicable regulations concerning water quality.

Preserve the cultural, historical, and recreational heritage of the lakeshore parks.

RESPONSE: This proposed development does not impact the heritage of the lakeshore parks because it is not adjacent to the park. It is located in the Private Use Zone.

Maintain and improve the formal character and open water vista of Gran! Park with no new above-ground structures permitted.

RESPONSE: The proposed development is remote from, and does not affect the formal character or the open water vista of Grant Park.

Increase the diversity of recreational opportunities while emphasizing lake-orienled leisure time activities.

RESPONSE: The proposed development will offer its patrons and residents opportunities near Lake Michigan so that they can enjoy the diverse activities found along the lakefront.

7. Protect and develop natural lakeshore park and water areas for wildlife habitation.

RESPONSE: The existing lakeshore park and water areas for wildlife habitation arc not adversely impacted. The site contains no natural lakeshore park or water areas.

8. Increase personal safety.

RESPONSE: The proposed development will add to safety and security in the area by constructing a new building that will provide new business opportunities in the area, add new residents and add vitality to the State Street environs.

Design all lake edge and lake construction to prevent detrimental shoreline erosion.

RESPONSE: The proposed development includes no lake edge or in-lake construction and therefore, this policy is not applicable.

Ensure a harmonious relationship between the lakeshore parks and the community edge, but in no instance will further private development be permitted East of Lake Shore Drive.

RESPONSE: The proposed development includes no land east of Lake Shore Drive. The proposed use of retail/residential is consistent with its environs, thus enhancing the relationship between the lakeshore parks and the community edge.

Improve access to the lakeshore parks and reduce Ihrough vehicular traffic on secondary park roads.

RESPONSE: The proposed development will not contribute to vehicular traffic on secondary park roads. No adjustments to existing public rights-of-way are needed or proposed.

Strengthen the parkway characteristics of Lake Shore Drive and prohibit any roadway of expressway standards.

RESPONSE: The proposed development does not include any roadway, let alone a roadway of expressway standards. Thus, there is no impact on Lake Shore Drive.

Ensure that all port, water supply, and public facilities are designed to enhance lakefront character.

RESPONSE: There are no port activities or public facilities at the site. The water supply will meet the provisions of the Municipal Code. There is no impact to the lakefront character.

Coordinate all public and private development within Ihe water, park, and community zones.

RESPONSE: The Applicant has concurrently filed a Planned Development application and is engaged in discussions with the City of Chicago Department of Housing &. Economic Development, which is the coordinating agency for this location. The site will become a vibrant part of the community and enhance the retail/pedestrian character of North State Street.

PART FOUR: POTENTIAL IMPACT OF THE PROPOSAL

11. Thirteen Purposes

I. To promote and protect the health, safety, comfort, convenience, and the general welfare

of the people, and lo conserve our natural resources;

RESPONSE: The public health, safety and welfare will be promoted by the implementation of this proposal as it will provide new business and residential opportunities. The proposal meets the requirements ofthe Chicago Zoning Ordinance, and will be constructed in an energy-efficient manner thus aiding in the conservation of natural resources.

To identify and establish the Lake Michigan and Chicago Lakefront Protection District and to divide that District into several zones wherein any and all development or construction, as specified in Article V hereinafter, shall be specifically restricted and regulated;

RESPONSE: The site lies in the Private Use Zone of the Lake Michigan and Chicago Lakefront Protection Ordinance. The Applicant is complying with the requirements of the Lakefront Ordinance by seeking approval hereunder for the proposed development in accordance with the policies and purposes set forth in the Lakefront Ordinance.

To maintain and improve the purity and quality of the waters of Lake Michigan;

RESPONSE: The proposal will have no adverse impact on the water quality of Lake Michigan as it is not adjacent to Lake Michigan.

To insure that construction in the Lake or modification of the existing shoreline shall not be permitted if such construction or modification would cause environmental or ecological damage to the Lake or would diminish water quality; and to insure that the life patterns offish, migratory birds and other fauna are recognized and supported;

RESPONSE: There will be no construction activities in the Lake or modification of the shoreline. Neither ecological or environmental damage nor any adverse impact on water quality will result from this proposal.

To insure that the Lakefront Parks and the Lake itself are devoted only to public purposes and to insure the integrity of and expand the quantity and quality of the Lakefront Parks;

RESPONSE: The integrity of die Lakefront Parks and Lake arc respected in this proposal, as the property is located in the Private Use Zone and has no impact on Lakefront Parks.

To promote and provide for continuous pedestrian movement along the shoreline;

RESPONSE: The site does not physically border the Lakefront shoreline, and Uius, this purpose is inapplicable.

To promote and provide for pedestrian access to the Lake and Lakefront Parks from and tttrougli areas adjacent thereto at tegular intervals of one-fourth mile and additional places wherever possible, and to protect and enhance vistas at these locations and wherever else possible;

RESPONSE: The proposal does not impact access to the Lake or the Lakefront Parks as it does not border the Lake or Lakefront Parks.

8. To promote and provide for improved public transportation access to the Lakefront;

RESPONSE: The. proposal docs not impact public transportation access to the lakefront.

To insure that no roadway of expressway standards, as hereinafter defined, shall be permitted in the Lakefront Parks;

RESPONSE: The proposal docs not inctudc a roadway of any kind.

To insure that development of properties adjacent to the Lake or the Lakefront Parks is so defined as lo iniplcni.nl the above-slated purposes, provided, however, that with respect to property located within the Private Use Zone as established by Article V, VI, and LX of this Ordinance, the permitted use, special use, lot area per dwelling unit, and floor area ratio provisions of the Chicago Zoning Ordinance, Title 17 of the Municipal

1 1

Code of Chicago, shall govern except where such provisions are in substantial conflict with (he purposes of this Ordinance or the Fourteen Basic Policies of the Lakefront Plan of Chicago;

RESPONSE: The proposal will comply with all provisions of the Chicago Zoning Ordinance and does not conflict with the purposes and policies of the Lakefront Plan of Chicago.

To achieve the above-stated purposes, the appropriate public agency should acquire such properties or rights as may be necessary and desirable;

RESPONSE: This property is not under consideration by any public agency for acquisition.

To define and limit the powers and duties of the administrative body and officers as provided herein;

RESPONSE: This application does not define or limit Ihe powers and duties of any administrative body or officers.

Nothing contained in the Lake Michigan and Chicago Lakefront Protection Ordinance shall be deemed lo be a waiver or consent, license or permit to use any property or to locate, construct or maintain any building, structure or facility or to carry on any tTade, industry, occupation or activity which may be otherwise required by law.

RESPONSE: The Applicant will fully comply with all applicable laws and further understands that any approval under the Lakefront Protection Ordinance will not constitute final approval to construct or use the proposed building.

12501OIJ

Planned Development Application for 1149-1167 North State Street

There are two properties which are included in the proposed PD. The Applicant, Elm State Property, LLC ownsl 149-1159 North State Street. The other property, 1163-1167 North State Street, is owned by Division State Property 1. LLC. Division State Property 1, LLC has authorized Elm State Property, LLC to be the Applicant for purposes of the PD.

Elm State Property. LLC

managed by DRW Management 1, LLC
owned by DRW-M Investor 1 (100%)

DRW-M Investor 1

managed by DRW Management 1, LLC
owned by DRW Real Estate Investments, LLC (80%); MF Partners, LLC (20%)

DRW Real Estate Investments. LLC

managed by DRW Management 1, LLC
owned by DRW Holdings, LLC (100%)

MF Partners, LLC

managed by MMF Member, LLC
owned by MMF Member, LLC (50%); L.l. MF Partners, LLC (50%)

DRW Holdings. LLC

managed by Donald R. Wilson, Jr.
owned by Donald R. Wilson, Jr. (63.8%); Kenneth S. Brody (19.4%)

DRW Management 1, LLC

managed by Donald R. Wilson, Jr.
owned by DRW Real Estate Investments, LLC (100%)

MMF Member. LLC

managed by Mark Hunt
owned by Phoenix Trust (80%); Mark Hunt (20%)

L.I. MF Partners, LLC

managed by FredLatsko
beneficial owner is Latsko Dynasty Trust (99.09%) - Terrence Raser, Trustee

Phoenix Trust

Robert Levin, Trustee
beneficial Owner is Mark Hunt (100%)

Latsko Dynasty Trust

Terrence Raser, Trustee
beneficial owners are Julie A. Latsko; William A. Latsko; descendants of William A. Latsko (specific interests of the beneficiaries are not fixed and cannot be ascertained, but the total is 100%)

Division State Property 1, LLC

managed by DRW Real Estate Management 1, LLC
owned by DRW Real Estate Investments, LLC (100%)

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Signed and sworn to before me on [date] jZ-j'T I ^ , by

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M u :v=-t

[state].

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This recertification is being submitted in connection with PP at Ml-HM w. sn<nz [identify the Matter]. Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date fiirnished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.

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y//(y^f/7 Notary Public.

Commission expires

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Date:

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TSorO jAW \ \Qyi. ■» (ftiy~

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Ver. 11-01-05

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signed and sworn to before me on [date] I <■'■(, I -' \,y

...iHx.l fySlMfi^ \ at C';V;iV. County,_U_ [state].

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(Print or type la^al name of Disclosing Party)

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(sign here)

Print or type name of signatory: Title of signatory:

12- ifi-l3

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[state].

Signed and sworn to before me on [date]

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m *r m

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e of Disclosing Party)

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_,by

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"' i ■ ■ i

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[identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute litis EDS recertification on behalf of the Disclosing Patty, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS arc true, accurate and complete as of the date furnished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.

(sign here) Print or type name of signatory:

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Trustee

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OFFICIAL SEAL MARIANNE GORMAN Notary Public - Stale ot Illinois ;My Commlatlon faplrw PecaOgW

Ver. U-OI-OS

Department of Planning and Development city of chicago

MEMORANDUM

TO:

Alderman Daniel S. Solis

Chairman, City Council Committee on Zoning

FROM:

Andrew J. Mooney / Secretary / Chicago Plan Commission

DATE:

Janauary 17, 2014

RE: Proposed Planned Development for property generally located at 1149-67 North State Street.

On January 16, 2014, the Chicago Plan Commission recommended approval of the proposed planned development submitted by Elm State Property LLC. A copy of the proposed planned development is attached. I would very much appreciate your assistance in having this introduced at the next possible City Council Committee on Zoning hearing.

Also enclosed is a copy of the staff report to the Plan Commission which includes the Department of Planning and Development, bureau of Planning and Zoning recommendation and a copy of the Resolution. If you have any questions in this regard, please do not hesitate to contact me at 744-5777.

cc: Steve Valenziano

PD Master File (Original PD, copy of memo)

121 NORTH LAS AU,E STREET, ROOM 1000. CHICAGO, ILLINOIS G0602

1/14/2014

Chicago Plan Commission

January 16, 2014

1119-1167 N. State Street ELM STATE PROPERTY, LLC

1-/1-4/2014

-mm.

f.'.-::o-s3'.fv^:

1/14/2014

1-/14/2014

FINAL

REPORT to the

CHICAGO PLAN COMMISSION from the

DEPARTMENT OF PLANNING AND DEVELOPMENT BUREAU OF ZONING AND LAND USE

JANUARY 16, 2014

FOR APPROVAL:

LAKE MICHIGAN AND CHICAGO LAKEFRONT

PROTECTION ORDINANCE APPLICATION NO. 632

AND RESIDENTIAL BUSINESS PLANNED DEVELOPMENT

APPLICANT:

ELM STATE PROPERTY, LLC

LOCATION:

1149-67 NORTH STATE STREET

Pursuant to the provisions of the Chicago Zoning Ordinance, Title 17 of the Municipal Code of Chicago, the Department of Planning and Development hereby submits this report and recommendation on a proposed Institutional Planned Development for your review and recommendation to the Chicago City Council. The application for this amendment to the Chicago Zoning Ordinance was introduced into the City Council on July 24, 2013. Notice of the public hearing was published in the Chicago Sun-Times on January 1, 2014. The applicant was separately notified of this public hearing.

The site is currently zoned DX-7, Downtown Mixed-Use District and is also located within the Lake Michigan and Chicago Lakefront Protection District. The applicant proposes to rezone the site to a Residential Business Planned Development to allow the construction of a residential condominium building with retail on the ground floor. The building as designed will allow for a 25-story mixed-use building with ground floor retail, 40 dwelling units, and 74 accessory parking spaces.

This application is submitted by the Applicant, as a mandatory planned development pursuant to Section 17-8-0511 Tall Buildings, which states that a planned development review and approval is required when the proposed project meets or exceeds 155 feet in the DX-7 Downtown Mixed-Use District.

SITE AND AREA DESCRIPTION

The approximately 0.5-acre site is located at State Street between Division and Elm Streets. It is located in the Near North Side Community Area. The rectangular-shaped site is bounded by Division Street on the north, residential and business property on the east, Elm Street on the south and State Street on the west. The CTA Red Line tunnel extends directly below the southeast corner of the site. A 10-foot wide private alley abuts the east side of the southern half of the site.

The site itself includes one two-story commercial building and one vacant three-story residential building with ground floor retail space. The site is within the Private Use Zone of the Lake Michigan and Chicago Lakefront Protection District and within the Gold Coast Historic District. State Street abutting the site is a Pedestrian Street. There are no buildings on the site that are Chicago Landmarks and no buildings that have been rated as potentially significant in the broader context of the city, state, or county ("red") or as potentially significant in the context of the surrounding community ("orange") by the Chicago Historic Resources Survey.

The site is served by the CTA's #36 (Broadway) bus line. The nearest CTA train station is the Clark/Division Red Line station located approximately two blocks west of the site.

PROJECT DESCRIPTION

The existing two-story commercial building on the north half of the site would remain. The three-story building on the south side of the site would be razed to be replaced by a twenty-five-story, 335-foot tall condominium residential building with ground floor retail space.

The new building would contain forty (40) three-bedroom units, 74 off-street parking spaces, and an amenities floor with common space. Retail space would be located on the ground level fronting State Street.

DESIGN

The facade of the residential floors of the building would be clad with a metal and glass wall system and the rooftop mechanical equipment would be screened by with the same materials. The upper residential floors would be set back significantly from both the north and west property lines. The retail space would be setback approximately 3 feet from the west property line, with the parking podium above creating an overhang.

The 4-story parking podium would extend to the north, south and west property lines and to the private alley on the eastern side. The Elm Street and State Street facades would be clad in an architectural masonry wall panel system. The north elevation facade would be clad in a synthetic stucco wall system. The east facade would be comprised of painted architectural concrete on the ground floor and a synthetic stucco wall system above.

ACCESS and CIRCULATION

Motor vehicle access to the parking podium would be via a new curb cut on Elm Street at the southeast corner of the site adjacent to the private alley. The residential lobby entryway would be off Elm Street, while two retail entrances would be located on the State Street side. Two off-street parking spaces would be accessed from the private alley and a loading dock would be accessed from the public alley at the northeast corner of the new building.

LANDSCAPING and SUSTAINABILITY

Street trees would be planted on Elm Street adjacent to the site. The building would have a total 50.1% green roof comprised of space located on various floor levels including the top floor, private balconies on the 23^rd and 25^,h floors, and landscaped planters on the amenities level on the 5^th floor.

BULK/USE/DENSITY

The site is currently zoned DX-7. The project would make use of the affordable housing FAR bonus for an additional 1.75 FAR, for a total FAR of 8.75. The new building would also make use of FAR available from the portion of the site encompassing the existing 2-story building.

At 40 units, the proposed development is far below the maximum threshold of 200 dwelling units for the DX-7 district. The neighborhood surrounding the project site includes many residential and mixed-use residential/commercial buildings, several of which are of similar height as the proposed building.

RECOMMENDATION

The Department of Planning and Development has reviewed the project materials submitted by the Applicant for a planned development and have concluded that the proposed development would be appropriate for the site for the following reasons:

The project meets the criteria and objectives set forth in Section 17-8-0900 of the Zoning Ordinance and its adoption would not have any adverse impact on the public's health, safety, or welfare;
The proposed development is compatible with the character of the surrounding area which includes primarily residential and mixed residential/commercial uses similar to the proposed development as well as several buildings of similar height and similar or greater density;
The public infrastructure facilities and city services will be adequate to serve the proposed development at the time of occupancy. The proposed Planned Development has been reviewed by the Chicago Department of Transportation and all requested changes have been made;
Motor vehicle parking would be accessed from the private alley and by a driveway from Elm Street. Pedestrian/vehicle conflicts will be minimized by the significant setback of the parking entrance door, providing a greater site angle for drivers, and by a pedestrian warning light at the entrance;
Pedestrian Orientation. The proposed project will allow unimpeded pedestrian flow on North State Street. The entire street frontage of the building is enlivened by a glass facade looking directly onto the street frontage. The pedestrian environment surrounding the proposed development will be enhanced by the setback of the retail space from the public sidewalk along State Street, and by the new proposed parkway planters and trees along Elm Street; also located within the Lake Michigan and Chicago Lakefront Protection District.
Urban and Building Design. The building's modern design emphasizes the contrast among the various types of architectural styles and vocabulary along North State Street.

7. Copies of the application have been circulated to other City departments and agencies and no comments have been received; the project will comply with the requirements for access in case of fire and other emergencies.

The Department of Planning and Development has reviewed the project materials submitted by the applicant for Lakefront application No. 632 and has concluded that this proposal would be in compliance with the applicable Policies of the Lakefront Plan of Chicago and the Purposes of the Lake Michigan and Chicago Lakefront Protection Ordinance, as they apply to development in the Private-Use Zone, specifically:

Policy No. 3 (Continue to improve the water quality and ecological balance of Lake Michigan) and Purpose No. 3 (To maintain and improve the quality of the waters of Lake Michigan).

A vegetated green roof system and on-site storm water retention systems will reduce storm water run-off. All sanitary and storm water runoff will be directed to the City's sewer system and will not enter Lake Michigan.

Policy No. 8 (Increase personal safety)

The project will maintain and possible enhance pedestrian activity near the subject site. Additionally, the completion of the previously stalled project will provide a better aesthetic quality for the adjacent properties and for the pedestrians walking through the area.

Policy No. 10 (To ensure a harmonious relationship between the lakeshore parks and the community edge, but in no instance will private development be permitted east of Lake Shore)

The proposed development falls within the Private-Use Zone of the Lake Michigan and Chicago Lakefront Protection District and has been and will continue to be consistent and conform to the District's restrictions and regulations. The site will be developed with a 25-story 40 dwelling unit building that is within the context of the surrounding neighborhood and will continue to maintain this harmonious relationship.

Policy No. 14 (Coordinate all public and private development within the water, park and community zones)

The applicant is committed to working with the community to ensure that the proposed development of the subject property will have minimal impact on the surrounding neighborhood.

Purpose No. 10 (To insure that development of properties adjacent to the Lake or Lakefront Parks is so defined as to implement the above-stated purposes).

Page 4 of 5

The proposed project will be constructed in accordance with all applicable provisions of the Chicago Zoning Ordinance and Building Code.

With respect to the Policies and Purposes not enumerated here, the Department of Planning and Development has determined that they are either not applicable to development in the Private-Use Zone or that the proposed project will not have a detrimental effect on the Lake Michigan shoreline or any wildlife habitats therein. The proposed project is separated from the shoreline, does not contemplate the introduction of new roadways, does not reduce existing open space and does not interfere with existing access to, or use of, Lake Michigan and its park system.

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 and Lake Michigan and Chicago Lakefront Protection Ordinance (Application No. 632) be approved and that the recommendation to the City Council Committee on Zoning, Landmarks and Building Standards be: "As Amended, Passage Recommended."

Page 5 of 5

DEPARTMENT OF PLANNING and DEVELOPMENT CITY OF CHICAGO

RESOLUTION

RESIDENTIAL BUSINESS PLANNED DEVELOPMENT 1149-1167 NORTH STATE STREET LAKE MICHIGAN AND CHICAGO LAKEFRONT PROTECTION ORDINANCE

APPLICATION No. 632

WHEREAS, The applicant, Elm State Property, LLC, proposes to establish a Residential Business Planned Development and achieve a maximum F.A.R of 8.75 via two Density Bonuses; Upper Level Set Back and Affordable Housing. The applicant proposes to construct a multi-story mixed-use building with 40 dwelling units, 74 accessory parking spaces, with ground floor retail space; and

WHEREAS, This development is being submitted by the applicant as a mandatory planned development application and an application for a Planned Development was introduced to the City Council on July 24, 2013; and

WHEREAS, the property is located within the Private Use Zone of the Lake Michigan and Chicago Lakefront Protection District and therefore requires Chicago Plan Commission approval under the Lake Michigan and Chicago Lakefront Protection Ordinance; and

WHEREAS, Lakefront Protection Ordinance Application No. 632 was filed with the Department of Planning and Development on July 29, 2013; and

WHEREAS, proper legal notice of the hearing before the Chicago Plan Commission was published in the Chicago Sun-Times on January 1, 2014. The proposed Zoning Application and Lakefront Protection Ordinance Application were considered at a public hearing by this Plan Commission on January 16, 2014. 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

121 NORTH LASALLE STREET, ROOM 1000, CHICAGO ILLINOIS 60602

WHEREAS, the Department of Planning and Development recommended approval of the applications, with the recommendation and explanation contained in the written report dated January 16, 2014, a copy of which is attached hereto and made a part hereof; and

WHEREAS, the Chicago Plan Commission has fully reviewed the applications 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 January 16, 2014 giving due and proper consideration to the Chicago Zoning Ordinance; and

NOW, THEREFORE, BE IT RESOLVED BY THE CHICAGO PLAN COMMISSION:

LF No. 632

THAT the final applications dated January 16, 2014 be approved as being in conformance with the provisions, terms and conditions of the corresponding Zoning and Lakefront 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 January 16, 2014; 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 application.

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

i^. the Applicant

[ ] 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:

3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name, of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: 'oHD I/O ■ MPttMfrniM $ <PTftD
Telephone: T.P.&L.'Si Fax: , S^[. Slu> I Email: bMglMiM^ EbPiAJ- (G^
Name of contact person: DAVl P Ai/-J?.%t)AJ _r

\ .-■ *■

Federal Employer Identification No. (if you have one): j ■"■
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):

PlA'TOtVcS fr ft rr/ m.r>PaAKA)T nils* tteKioUP; fo^ /Ml -//^L1 A) SfA<&

Which City agency or department is requesting this EDS?__J>jt23^

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Vcr. 01-01-12 Page 1 of 13

SECTION II- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

Person

Publicly registered business corporation

Privately held business corporation

Sole proprietorship

General partnership

Limited partnership

Trust

p^j-> Limited liability company [] Limited liability partnership [ ] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

[ ] Yes [ ] No

[ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[]Yes []No lVi\N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the

Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes h^No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain iri connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must cither ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

JWe ~?goo ottf (est )

C H i rfl t>c 6>&t>o I

(Add sheets if necessary)

[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V CERTIFICATIONS

COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes l^/No [ ] No person directly or indirectly owns 10% or more of the

Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[ ] Yes [ ] No

FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities

identified in Section II.B.l. of this EDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction Or contract under a. public transaction; a violation of federal of state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other Unit of local government.

3. The certifications in subparts 3, 4 and 5 concern:

«the Disclosing Party;

any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");

any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect lo Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

\j k i

Page 6 of 13

If the letters "N A," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a; complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the Gity of Chicago (if none, indicate with "N/A" or "none").

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a

complete list of a|l gifts that the Disclosing Party has given or caused to be given, at any time during the

12-month period preceding the execution date of this EDS, to an employee, or elected or appointed

official, of the Gity of Chicago. For purposes of this statement, a "gift" does not include: (i) anything

made generally available to City employees or to the general public, or (ii) food or drink provided in the

course of Official City business and having a retail value of less than $20 per recipient (if none, indicate

with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient,

fckj^k ,

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check one)

[ j is {j^is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person br entity in the Matter?

[ 3 Yes [TPNo

NOTE: If you checked "Yes" to. Item D.l., proceed to Items D.2. and D.3. If you checked "No" to. Item D.l., proceed to Part E.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue Of legal process at the suit of the City (collectively, "City Property Saje"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Parly must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

_NLjl. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the

Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are riot federal funding.

A. CERTIFICATION REGARDING LOBBYING

I. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, au officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[]Yes []No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes []No

Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City Contracts, work, business, br transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.OTg/Ethics, aiid may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

Ifthe City determines that any information provided in this EDS is false, incomplete or inaccurate, any contractor other agreement in connection with, which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contractor agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to die public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to: this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or. otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS.must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), die information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Parly represents and warrants that:

Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use; nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 Ifthe Disclosing Party is the Applicant, the Disclosing. Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

(Print or

e of Disclosing Part

my)

(Print or type name of person signing) (Print or type title of person signing)

Ml3

(state).

Notary Public.

Signed and sworn to before me on (date) "7

at QjPOy . County, \ U

Commission expires:

S Official Seal

\ Christine Woods

> Notary Public Slate of Illinois / My Commission Expires 02/06/2017

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only, by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner br as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild* father-in-laWj mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section HB.1.3-, ifthe Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party, and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ]Ycs

If yes, please identify below (1.) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

\/\ 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: £.L-f^\ SOVteT P<2.o"?Ki2.T\| M,f-

3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: &^L)0 lO ■ M AfMSfiM & J3<T3 6

U~ftcAlT(> -OXXfi Is ¹

Telephone: ^Q. Tip ■ 2>>k> | Fax: 7,\a.S3i_t. cnu> I Email: DMfcO^DM (^ftvgXja. (W
Name of contact person: D<°<Vi Q Mh^2-&g;Q .....
Federal Employer Identification No. (if you have one):j S
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):

G. Which City agency or department is requesting this EDS? D |-r"UTZb

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Vtr. 01-01-12

Page 1 of 13

SECTION II DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

[] Person My Limited liability company

[ ] Publicly registered business corporation [ j Limited liability partnership

[] Privately held business corporation [] Joint venture

[ ] Sole proprietorship [ ] Not-for-profit corporation

[ J General partnership (Is the not-for-profit corporation also a 501(c)(3))?

[ ] Limited partnership [ ] Yes [ ] Mo

[] Trust [] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

^Yes .[ ] No [ ] N/A

B IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, listbelow the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

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Name Business Address Percentage Interest in the

Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes /ThNo

If yes, please identify below the name(s) of such City elected official(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, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

t|bCheck here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS

COURT-ORDERED CHILD SUPPORT COMPLIANCE

Has any person who directly or indirectly owns 10% or more of the Disclosing Party heen declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes [W No [ ] No person directly or indirectly owns 10% or more of the

I Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[]Yes []No

FURTHER CERTIFICATIONS

Page 4 of 13

The Disclosing Party and, if the Disclosing Party is a legalentity, all of those persons or entities identified in Section ILB.l. of this EDS;

1. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
2. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification Or destruction of records; making false statements; or receiving stolen property;
3. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
4. 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
5. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect lo a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or.adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is.barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating-in violation of 720 ILCS 5733E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U^S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing.Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing.Party certified to the above statements.

8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate widi "N/A" or "none").

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the; 12-mohth period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything_:made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is ft^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 Parry pledges:

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Ifthe 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 words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or eritity in the Matter?

[]Yes

NOTE: If you checked "Yes" to Item D, 1., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to. Part E.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively; "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[]Yes fJNo

If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either 1. or 2. below. Ifthe Disclosing Parly checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

1. The Disclosing PaTty verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all. predecessor entities regarding records of investments or profits from slavery or slaveholder.insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing PaTty verifies that, as a result of conducting the search in step I above, the

Disclosing Party has found Tecords of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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 niade lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or ifthe letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B; CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.

Is the Disclosing Party; the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

U Yes [ ] No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

If you checked "No" to question 1. or 2. above, please provide an explanation:

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SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

The certifications, disclosures, and.acknowledgments contained in this EDS will become part of any contract or other agreement,between the AppHeant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action, with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cicyofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at Jaw, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS maybe made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes,, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. Ifthe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

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F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.PA. on the federal Excluded Parties List System ("EPLS") maintained by ihe U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2; above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has notprovided or cannot provide truthful certifications.

NOTE: Ifthe Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person sighing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

(Print or typjMiamc of Disclosing Party)

(Print or type name of person signing)

(Print or type title of person signing)

Official Seal Christine Woods Notary Public State of Illinois My Commission Expires 02/06/2017

(state).

Notary Public.

Commission expires:

Page 12 of 13

Signed and sworn to before me on (date) *~f

at [,(>() t County, I U

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS. is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner diereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section. n.B. La., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Parry is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership.interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ]Yes

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

^ 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: &UA SXrYTt Prg(S?fc72T~U l.JL

OR '

3. [ ] a legal entity with a right of control (see Section II.B: I.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: 0 \JQ- KH Jt~E>iSDAJ ^3^^>6
Telephone: bl 3. ,?>)lr ) Fax: h I^ &3 b I Email: b A>/J^5£>AJ@ C^UJ, / 0*1*
Name of contact person: V^AVi Q MgX-^/Q
Federal Employer Identification No. (if you have one):¹:
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):

?\ M\ MA \l j i Op wU \Ar\ hv A l A (k\A^Q . llW'//t> 7 N - SfA<f2

Which City agency or department is requesting this EDS? C^("fc/?^>

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 01-0M2

Page l of 13

SECTION II DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSLNG PARTY

1. Indicate the nature of the Disclosing Party:

] Person |p Limited liability company

] Publicly registered business corporation [ ] Limited liability partnership

] Privately held business corporation [ ] Joint venture

] Sole proprietorship [ ] Not-for>-profit corporation

] General partnership (Is the not-for-profit corporation also a 501(c)(3))?

] Limited partnership [ ] Yes [ ] No

] Trust [] Other (please spepify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

| Yes []No ['] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers, and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Ifthe entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name, and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf

Name Title

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interest of a member or manager in a limited liability company, br interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), die City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the

Disclosing Party

SECTION III -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes |$No

If yes,.please identify below the name(s) of such City elected qfficial(s) and describe such relationship(s):

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

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.

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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of Competent jurisdiction?

[ ] Yes t^No [ ] No person directly or indirectly owns 10% or more of the

Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

□ Yes []No

B. FURTHER CERTIFICATIONS

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2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities

identified in Section II.B.l. of this EDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, stale or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for.cause or dejfault;. and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including.actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.

3, The certifications in subparts 3, 4 and 5 concern:

- the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant lo the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce Cr 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.
Ifthe Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Hitv

Page 6 of 13

Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20, per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

KIqA¹* r _ , , _

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check; one)

[ ] is 'f^is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined iii Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes fpMo

NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation.for property taken pursuant to the City's eminent domain power does not Constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

If you checked "Yes" to Item D.L, provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check cither 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments oj profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

_2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the

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 VTL For purposes of this Section VL tax credits allocated by the City arid proceeds of debt obligations of the City are not federal funding.

A, CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or ifthe letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity lo influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities''.
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

If the Matter is federally funded, federal regulations require the Applicant ^nd all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations:

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

fJYes []No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, arid acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N,

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully With the applicable ordinances.

If the Gity determines that any information provided in this EDS is false, incomplete or inaccurate,, any contract br 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 )aw, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upou request Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing

Party must supplement this EDS up to the time the City takes action oh the Matter. If the Matter is a,

contract being handled by the City's Department of Procurement Services, the Disclosing Party must

update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of

Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified

offenses), the information provided herein regarding eligibility must be kept current for a longer period,

as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but.is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 Ifthe Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. oh the federal Excluded Parties List System ("EPLS") maintained by the U: S. General Services Administration.

F.3 Ifthe Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: Ifthe Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS: and Appendix A (if applicable) on behalf of the Disclosing Party, arid (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

pau3 tow, F&pfcrr //Q^^iiiA.(^r%₎^^Lc

(Sign here)

(Print or typeTteme of Disclosing Party)

(Print or type name of person signing)

(Print or type title of person signing)

zJieln

Signed and sworn to before me fln-(jdate) at (jJDO^ , County,

Commission expires:_

(state).

Notary Public.

Official Seal Christine Woods Noiary Public State of Illinois Mv Commission Expires 02/06/2017

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date, this EDS is sighed, the Disclosing Party or any "Applicable Party" or 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 spouseor domestic partner br as any of the following, whether by blood or adoption: parent, child, brother Or sister, aunt or uncle, niece or nephew, grandparent, grandchild, fatiier-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable. Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, ifthe 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 br any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes

If yes, please identify below (1) the namc.and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

^ 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: [ZJLtA STEYD-T P&DTi&lZDj iA^t.

OR '

3. (] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in

which the Disclosing Party holds a right of control: .

Business address of the Disclosing Party: S^LlO MrVQtSflM & <*?5(Yb

(U^lATrb )u l<-> rim l

Telephone: g>IP-SIj3 ,3l<l) Fax: S2L> Slla 1 Email: t>k>tO-$eto<9 fr&Ul A h>vy
Name Of contact person: T~)/Wl N]\^L^i$-£> fO

E: Federal Employer Identification No. (if you have one!

Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Which City agency or department is requesting this EDS? ]\t7^>

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Vcr. 01-01-12

Page 1 of 13

SECTION II DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:.

[ ] Person Mj Limited liability company

[ ] Publicly registered business corporation [ ] Limited liability partnership

[ ] Privately held business corporation [ ] Joint venture

[ ] Sole proprietorship [ ] Not-for-profit corporation

[ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))?

[ ] Limited partnership [ ] Yes [ ] No

[ ] Trust [ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business; in the State of Illinois as a foreign entity?

)Yes [ ] No [ ] N/A.

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

Ifthe entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

^Otvl.^ ft. VNjvUvokL Tfi - K,	*yvl/f<j £r<!
IO ^v

Page 2 of 13

Name Business Address Percentage interest in the

Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official.in the 12 months before the date this EDS is signed?

[ ] Yes j^c

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, Consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as. an employee of another includes undertaking to influence any legislative or administrative action.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must cither ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

fj^JjChe

(Add sheets if necessary)

^heck here ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS

COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code-Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support, obligations throughout the contract's term.

Has any person who directly or indirectly owns 10% or more of the. Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes fft No [.] No person directly or indirectly owns 10% or more of the

Disclosing Parly.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in cbmpliancewith that agreement?

U Yes [ ] No

FURTHER CERTIFICATIONS

I. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been.convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");

« any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests 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, die term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;

any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

bribed or attempted to bribe, or been convicted br adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or

made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid^rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the, Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.

The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

:rtyn^tio

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified lo the above statements.

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-montb period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, ox (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 alsq list the name of the City recipient.

_4kli^£r_. _: _ .

-C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is 1sj))is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will became, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with.the City."

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-150 of the Municipal Code have the same meanings when used in this Part D.

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes jSjbNq

NOTE: If you checked "Yes" to Item D.l, proceed to Items D.2. and D.3. If you checked "No" to Item D.L, proceed to Part E.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for .taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

If you checked "Yes" to Item D.L, provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the Giiy.

^>^J 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the

Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section. VI., If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING

1 List below the names of all persons or entities registered under the federal Lobbying D isclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not ah organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications, for the duration of the Matter and must make such certifications promptly available to the City upon request;

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Patty the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[] Yes [ ] No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the.Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with 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 of voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void); at law, or in equity, including terminating, the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments, to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must, update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal, in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F,2, Or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true; accurate and complete as of the date furnished to the City.

(Signhere)

(Print or tygp-^iame of Disclosing Party)

(Print or type name of person signing)

(Print br type title of person signing)

PjJm

Signed and^sworn to before me on (date) / ' / at f/f/'^ <L_. County, / (state).

Commission expires:

Notary Public.

Official Seal Christina Woods Notary Public Stale of Illinois My Commission Expires 02/06/2017

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which lias a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familialrelationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-iri-law, mother-in-law, sorwn-law,. daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister of half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section TJ.B'.'La., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, ifthe 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 tiian a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means die president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ]Yes

If. yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Parly submitting this EDS is:

[ ] the Applicant

[ ] 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:

3. I ] a legal entity with a right of control (see Section Il.B. 1.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: h *j b \/J . V\A <Q J)[ i rfril-n H^-O &
Telephone: 5>?-5V3 -f?¹ W Fax: filial Email: DAJ£LK>A) <? . D<2jV. Cc
Name of contact person: C)Ar~\jl O AA^^^/V

Federal Employer Identification No. (if you have one): / \

A_ _ j

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):

G. Which City agency or department is requesting this EDS? blfep

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 0141-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

NATURE OF THE DISCLOSING PARTY

] ]

] ] ]

I. Indicate the nature of the Disclosing Party: Person D

Publicly registered business corporation (

Privately held business corporation [

Sole proprietorship [

General partnership (

Limited partnership Trust

M Limited liability company ( ] Limited liability partnership [ ] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

t ] Yes [ ] No

[ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[]No

[] Yes

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

I. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Ifthe entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-1 54-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the

Disclosing Party

biUo ton GhWcrg /ami^iiu^ts _LL.e, iqq%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes p^No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (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.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

[ ] Check here ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS

COURT-ORDERED CHILD SUPPORT COMPLIANCE

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes [ ] No person directly or indirectly owns 10% or more of the

Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[ ] Yes [ ] No

FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

The Disclosing Parly and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:

1. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
2. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
3. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
4. 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
5. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Parly or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the M alter:

1. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
2. 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
3. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of slate or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33 E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[]Yes j)^No

NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.I., proceed to Part E.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either I. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

^\ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profils from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded contract, gTant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A. I. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[ J Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

Have you participated in any previous contracts or subcontracLs subject to the equal opportunity clause?

[ ] Yes [ ] No

If you checked "No" to question 1. or 2. above, please provide an explanation:

iPage 10 of 13

SECTION VII- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicaeo.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing

Party must supplement this EDS up lo the time the City takes action on the Matter. If the Matter is a

contract being handled by the City's Department of Procurement Services, the Disclosing Party must

update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of

Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified

offenses), the information provided herein regarding eligibility must be kept current for a longer period,

as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

D/vVSinAJ S7>rr& ?<d?£i?.t-l) I LLC.

Page 12 of 13

(Print or type name of person signing)

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B. 1 .a, if the Disclosing Party is a corporation: all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ]Yes

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS, Include d/b/a/ if applicable:

D&va)-AA ikwJcwn^ I j.ic^.

Check ONE of the following three boxes:

Indicate whether the Disclosing Parly submitting this EDS is:

f ] the Applicant

\/\ a legal entity holding a director indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: £L/W ^<^T7\tt-. P&'OP|E'&tU Ll£_.

OR '

3. [ ] a legal entity with a right of control (sec Section I I.B.I.) State the legal name of the entity in

which the Disclosing Party holds a right of control: ^

Business address of" the Disclosing Parly: SHO l^l- /UAtmV/\J v
Telephone: 313- §Hd-3\b ) Fax: 31 3. Safe. 'Oto H Email: OK )tlS<ltsj>'(tc-.-<<.L*j ■ t c»"\

D- Name of contact person: D^V|-D ,

E. Federal Employer Identification Np. (if you have one): , _ ).".';'

Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Which City agency or department is requesting this EDS? P) i t L

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete ihe following:

Specification # and Contract //

Vcr. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of the Disclosing Party:

Person |fa Limited liability company

Publicly registered business corporation [ ] Limited liability partnership

Privately held business corporation [ ] Joint venture

Sole proprietorship [ ] Not-for-profit corporation

General partnership (Is the not-for-profit corporation also a 501(c)(3))?

Limited partnership [ ] Yes [ ] No

Trust [ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3 For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

fc^Yes []No []N/A

B. IF THE DISCLOSING PARTY IS A LBGAL ENTITY:

1. List below the full names and titles of all executive oifficers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, whjch are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Name Title

Page 2 of 13

Name Business Address Percentage Interest in the

Disclosing Party

SECTION III ~ BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

13 Yes

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Parly's regular payroll.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party .Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

heck here if the Disclosing Party has.not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been, declared in arrearage ort .any child support obligations by any Illinois court of competent jurisdiction?

[] Yes

[ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[ ] Yes [} No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

| i

Page 4 of 13

The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local), terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a .CivilproCeeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local, government.
The certifications in subparts 3,4 and 5 concern:

the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or, any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors; the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

____

Page 6 of 13

Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

HOhte-, _:

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

4oA^ _:

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing PaTty certifies that the.Disclosing Party (check one)

[ ] is [ ] is not

a "financial institution" as defined in Section 2-32-455(b.) of the Municipal Code.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

Page 7 of 13

Ifthe letters "NA," the word "None," or no response; appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

t ] Yes (fa No

NOTE: If you checked "Yes" to Item D.l., proceed to Items D,2. and D.3. If you checked "No" to Item D.l., proceed to Part E.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

If you checked "Yes" to Item D.L, provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Parly must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and aJJ predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section

501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4, above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between, the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

If the Gity determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing

Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a

contract being handled by the City's Department of Procurement Services, the Disclosing Party must

update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of

Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified

offenses), the information provided herein regarding eligibility must be kept current for a longer period,

as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Parry or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE; Ifthe Disclosing Party cannot certify as to any of the items in F.l,, F.2. or F.3. above, an explanatory statement must be attached, to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) oft behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are, true, accurate and complete as of the date furnished to the City.

£ of Disclosing Party)

(Print or type By:.

(Print or type name of person signing) (Print or type title of person signing)

Signed and sworn to before me on (date) "7 j I £-) I 3> at DO Y County, [ (state).

Notary Public.

~X_^^,ly-'^r " " ; < Official Seal

QJJjMdA.

'1 I i /. / I' 7 > Christine Woods

Commission expires: ¹ ' ; . ? Notary Public state ofia^s'

Page 12 of 13

^v ¹ i > My Commission Expires 02/06/2017 ¹

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece Or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section H.B.l.a., ifthe Disclosing Party is a corporation; all partners of the Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners of the. Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ]Yes

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Parly submitting this EDS is:

[ ] the Applicant

[ ] 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:

3. [ ] a legal entity with a right of control (see Section I1.B.1.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: \k) , rAA (I I jrO ^> Q1A.I ~n &

QM UaAQ \Ls laD lab I

Telephone: ^-Pfd-t>' (W Fax: flbr I Email: DAJgLK>/0 <? . TiQJi). Co
Name of contact person: C)f*rui O 1^2L-&t> A ~r-~ -> -,

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):

Vlamtru-d lysffilop\MJ.n.r 0<rcliiAGfM( 0 I'll'^' ^TfifS~

G. Which City agency or department is requesting this EDS?_

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. (11-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

] Person

] Publicly registered business corporation

] Privately held business corporation

] Sole proprietorship

] General partnership

] Limited partnership

] Trust

M Limited liability company [] Limited liability partnership [ ] Joint venture [ ] Not-for-profit corporation

(Is the not-for-profit corporation also a 501(c)(3))?

[ ] Yes [ ] No

[ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No [}CN/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Ifthe entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Title

Name

Page 2 of 13

Name Business Address Percentage Interest in the

Disclosing Party

5^0 UJ. M/).ctt&« CMJtaajx) iu loQLpln I

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ J Yes r^No

If yes, please identify below the name(s) of such City elected official(s) and describe such rclationship(s):

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS

COURT-ORDERED CHILD SUPPORT COMPLIANCE

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes ^ J ^° P^erson directly or indirectly owns 10% or more of the

Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[ ] Yes [ ] No

FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies lo the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

The Disclosing Party and, if the Disclosing Parly is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, stale or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concern:

- the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Parly, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party lo any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or

1. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Ufa

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

8. To the best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is ^ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[]Yes MNo

NOTE: If you checked "Yes" to Item D.I., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

If you checked "Yes" to Item D. 1., provide the names and business addresses of the City officials or employees having such interest and identify ihe nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either I. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

PageS of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

X 1 ■ The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. 1. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A. 1. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[ J Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[]Yes []No

If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

Ifthe City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing

Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a

contract being handled by the City's Department of Procurement Services, the Disclosing Party must

update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of

Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified

offenses), the information provided herein regarding eligibility must be kept current for a longer period,

as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code

The Disclosing Party represents and warrants that:

Page 11 of 13

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

(Print or type-name of Disclosing Party)

(Print or type name of person signing)

Aitle

(Print or type-title of person signing)

Signe at

Commission expires

nd sworn to before me on (date) VO\C- County, "TIL

: 2-1 <* I' ^

(state).

Notary Public.

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B. I .a., if the Disclosing Party is a corporation; ail partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ J Yes

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity lo which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

?\\o£r>\% T

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [ ] the Applicant

2. ^^.a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest:, £:Ly\ ^^PtT£ Ps\o?££-Vy L-i. ^c-

3. [ ] a legal entity with a right of control (see Section II.B.I.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: jfjOOf IN- ft/juSTi-D
Telephone: 9)50- /b$0 Fax: SSO'tb^ Email: PlHu^fc oeyca.Qo^
Name of contact person: MA&r<~. H^T
Federal Employer Identification No. (if you have one): ; .
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Which City agency or department is requesting this EDS? j>H£0

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

[ ] Limited liability company [ ] Limited liability partnership [ ] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

[ ] Yes [ ] No

[ ] Other (please specify)

1. Indicate the nature of the Disclosing Party: ] Person [ ] Publicly registered business corporation [ ] Privately held business corporation [ ] Sole proprietorship [ ] General partnership (]

] Limited partnership

pi Trust [

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[]No

[] Yes

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership'or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

Page 2 of 13

Name Business Address Percentage Interest in the

Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes tyf No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

N;ime (indicate whether Musmcss Rclnlionship lo Disclosing Parly Fees (indicate whether

retained or anticipated .Address (subcontractor, attorney, paid or estimated.) NOTIi:

to he rci.lined) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Aikl sheets if necessary)

[ ] Cheek here if the Disclosing Party has not retained, nor expects lo retain, any such persons or entities. SUCTION V - CKRTIHCA'HONS

A. COURT-OKDKKLD CHILI) SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-11 5. substantial owners of business entities thai contract w ill) the City must remain in compliance with their child support obligations throughout ihe contract's term.

Has any person who directly or indirectly owns 10% or more of the Disclosing Parly been declared in arrearage on any child .support obligations by any Illinois court of competent jurisdiction?

\ ] Yes |^| No [ ] No person directly or indirectly owns 1 0% or more of the

Disclosing Party.

If "Yes," has ihe person entered into a court-approved agreement for payment of all support owed and is ihe person in compliance, with that agreement?

( | Yes | | No

1). RIRTIIHR CKRTIHCA TIONS

I. Pursuant lo Municipal Code Chnpier 1-23. Article I (■'Ariicle l")(which llic Applicant should consult for defined terms (.e.g., "doing business") and legal rei|uireinenls), if ihe Disclosing Parly submitting this HDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neilher ihe Applicant nor any controlling person is currently indicted or charged with, or lias admitted guilt ol", or lias ever been convicted ol', or placed under .supervision for. any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, pcrjuiy. dishonesty or deceit against an officer or employee of the City or any sister agency: anil (ii) ihe Applicant understands and acknowledges that compliance with Ariicle I is a continuing requirement for doing business with the City. NO 11-!: If Article L applies lo the Applicant, the permanent compliance iimclramc in Ariicle I supersedes some live-year compliance timeframes in ceriificaiions 2 and 3 below.

Page -1 of 13

2. The Disclosing Puny and, if ihe Disclosing Parly is a legal entity, all of those persons or entities identified in Section 11.13.1. of this liDS:

aro nol presently debarred, suspended, proposed for debarment, declared ineligible or soluniarily excluded from any transactions by any federal, stale or local unit of government:
have not, within a five-year period preceding ihe date of this F.DS, been convicted of a criminal offense, adjudged guilty, or hail a civil judgment rendered against ihem in connection with: ohtitining, attempting to obtain, or performing a public (federal, slale or local) transaction or eoniraci under a public transaction: a violation of federal or stale aniiirust staiuies; fraud; embezzlement: diefl; forgery: bribery; falsification or destruction ol" records: making false xlalenienls: or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by. a governmental entity (federal, slale or local) with committing any of the offenses scl forth in clause B.2.b. of this Section V;
have nol, within a five-year period preceding Ihe dale of this 1IDS, had one or more public transactions (federal, state or local) terminated for cause or default: and
have nol. within a five-year period preceding the dale of (his L"DS, 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 C'ily or by Ihe federal government, any slate, or any other unit of local governtnenl.

.3. The certifications in subparts .3, 4 and 5 concern:

- the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by ihe Disclosing Party in connection with the Matter, including but nol litnilcd lo all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any ''AlTiliaicd Hntily" (meaning a person or entity (hat, directly or indirectly: controls the Disclosing Party, is controlled by Ihe Disclosing Parly, or is. with ihe Disclosing Parly, under common control of another person or entity. Indicia ofconlrol include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or oi ganization of a business entity following the ineligibilily of a business entity (o do business with federal or stale or local government, including Ihe Oiiy, using substantially the same management, ownership, or principals as the ineligible eiuily): with respect lo ('ontraclors. the term AlTiliaicd lintity means a person or entity that directly or indirectly controls the Contractor, is controlled by il. or, with ihe ("ontraclor, is under common control of another person or entity:
any responsible official of ihe Disclosing Party, any ("ontraclor or any Affiliated Iniily or any other ii iTicial. agent or employee of the Disclosing Parly, any < *on( ractor or any A f'("i lint eel lint icy. acting pursuant to the direction or authorization of a responsible official of the Disclosing Parly, any (.'ontraclor or.iny Affiliated Lntily (collectively "Agents").

Page 5 ol 13

Neither the Disclosing Party, nor any Contractor, nor any AlTiliaicd Emily of oilher die Disclosing Party or any Contractor nor any Agents have, during ihe five years before ihe dale this liDS is signed, or. wilh respect lo a Contractor, an Affiliated lintity. or an .Affiliated F.nlily of a Contractor during ihe five yeais before ihe dale of such Contractor's or AlTiliaicd Emily's contract or engagement in connection with die VI alter-

bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency ofihe federal government or of any stale or local government in ihe United Slates- of America, in that officer's or employee's official capacity;
agreed or colluded will) other bidders or prospective bidders, or been a parly 10 any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement lo bid a fixed price or otherwise: or

e. 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

d. violated Ihe provisions of Municipal Code Section 2-^c>2-ol() (.Living Wage Ordinance).

Neither the Disclosing Parly, Affiliated lintity or Contractor, or any of their employees, officials, nge-nls or partners, is barred from contracting with any unit of slate or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/3311-3; (2) bid-rolaling in violation of 720 ILCS 5/3312-4; or (3) any similar offense of any slale or of ihe United Stales of America that contains ihe same olenicnls as (he offense of bid-rigging or bid-rolaiing.
Neither the Disclosing Parly nor any AlTiliaicd finlily is listed on any of the following lists maintained by Ihe Office of Foreign Assets Control of ihe U.S. Department of the Treasury or lire Bureau of Industry and Seeurily of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, ihe Denied Persons I.isi, (he Unverified I,isi, the lintity I.isi and ihe Debarred List,

(■>. fhe Disclosing Party understands and vhall comply with Ihe applicable reipi iremoii ts of duplets 2o5 (Legislative Inspector General), 2-56 (Inspector (ieneral) and 2-156 (Governmental liihics) of the Municipal Code.

7. If the Disclosing Pany is unable lo certify lo any of ihe above slnienicnis in this Part H (Further fortifications), ihe Diselosiim Parly must explain below:

.An, _i. ' _ _ ...

Page 6 of 13

If tho letters "NA." the word "None." or no response appears on the lines above, il will he conclusively presumed lhai the Disclosing Party ccrtilied to ihe above statements.

.S', To ihe best of Ihe Disclosing Parly's knowledge al'tcr reasonable inquiry, (he following is a complete list of all current employees of the Disclosing Party who were, at any time dining the I 2-month period preceding the execution dale of'lhis EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or ■■none'").

^l). 1'6 the best of ihe Disclosing Party's knowledge after reasonable inquiry, the following is; a complete list of all gifts dial the Disclosing Parly has given or caused lo be given, at any lime during ihe 1 2-monih period preceding the execution date of this EDS, lo an employee, or elected or appointed official, of ihe City of Chicago. I-or purposes of this statement, a "giJ'i" does nol include: (i) anything made generally available lo Cily employees or to the general public, or(ii) food or drink provided in the course, of official City business and having a retail value of less than S20 per recipient (if none, indicate wilh "N/A" or "none"). As lo any gift listed below, please also lis! ihe name of die Cily recipient.

\vU.,i--l'^ _

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Parly certifies ihal ihe Disclosing Parly (check one)

f ] is }/.] is nol

a "financial institution" as defined in Section 2-32-455(b) of I he Municipal Code.

If Ihe Disclosing Party IS a financial institution, then ihe Disclosing Parly pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of (he Municipal Code. We further pledge I hat none of our affiliates is. and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in ihe loss of Ihe privilege of doing business with the Cily."

Ifthe Disclosing Party is unable to make this pledge because il or any of its affiliates (as defined in Section 2-32-'l:>5(li') of the Municipal Code) is a predaioiy lender within the meaning of Chapter 2-32 of ihe Municipal Code, explain here (attach additional pages if necessary):

Paee 7 of 13

If ihe letters "NA," ihe word "None." or no icsponsc appeals on the lines ahove. it will be conclusively presumed lhal the Disclosing Party certified lo the above statements.

D, CERTIFICATION REGARDING IN f PR EST IN CITY BUSINESS

Any words or lerms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Pari D.

In accordance wilh Section 2-1 56-1 10 of ihe Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any oilier person or entity in the Mailer?

[ ] Yes |yj No

NOTE: If you chocked "Yes" lo llcm I).I., proceed lo Items D.2. and D.3. If you checked "No" lo Hem D.I., proceed lo Pail E.

Unless sold pursuant lo a process of competitive bidding, or otherwise permilled. no Cily eleelecl 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 ihe purchase of any properly that (i) belongs lo the City, or (ii) is sold for taxes or assessments, or (iii) is sold hy virtue of legal process al the suit of Ihe Cily (collectively, "Cily Properly Sale"). Compensation for property taken-pursuant to the City's eminent-domain power docs not constitute a financial interest within the meaning of this Part D.

Does the Mailer involve a Cily Properly Sale?

I "J Yes I] No

If you checked "Yes" to llcm D.I., provide the names and business addresses of the City officials or employees having such interest and identify Ihe nature of such interest:

Name Business Address Nature uf Interest

I. fhe Disclosing Parly further eerlifies lhal no prohibited financial interest in the Matter will be acquired hy any City official or employee.

I:. t'l:RT ll-'ICA I ION REGARDING SLAVERY ERA BUSINESS

Please check eiihei I. >>r 2. below. Ifthe Disclosing Party cheeks 2 the Disclosing Parly must disclose lielow or in an att:u. hiueni to this EDS all inlbimation required by patagiaph 2. failure to

Page K of ! .i

comply wilh these disclosure requirements may make any contract entered into with the City m conned ion will) I lie Mailer voidable by the City.

The Disclosing Party verifies that the Disclosing Party has searched any and all records of ihe Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the shivery era (including insurance policies issued to slaveholders that provided coverage for damage lo or injury or death of their slaves), and the Disclosing Party has found no such records.
The Disclosing Parly verifies lhal. as a result of conducting Ihe search in step I above, ihe Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies lhal ihe following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SUCTION VI - CERTM-'ICATIONS FOR FT. DE RALLY FUND Ll) .VIATTKILS

NOTK: Ifthe Matter is federally funded, complete this Section VI. Ifthe M utter is not federally funded, proceed to Seeiion VII. For purposes or"this Section VI, lax credits allocated by the City ami proceeds of debl obligations of tlicCilyare nol federal funding.

A. CERTIFICATION REGARDING LOBBYING

I. List below the names of all persons or enlilies registered under the federal Lobbying Disclosure Act of 1995 who have made lohbying contacts on behalf of die Disclosing Party with respect lo Ihe Matter: (Add sheds if necessary'):

(If no explanation appears or begins on Ihe lines above, or if the letters "NA" or ifthe word "None" appear, il will he conclusively presumed lhal Ihe Disclosing Party means that NO persons or enlilies registered under the Lobbying Disclosure Acl of 1995 have made lobbying contacts on behalf of the Disclosing Parly with respect to the Mailer.)

2. fhe Disclosing Parly has not spent and will not expend any federally appropriated funds lo pay any person or entity listed in Paiagraph 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 hy ipplicable federal law. a member of Congress, an officer <>r employee ofCongress. or an employee of a member of Congress, in connection wilh the award of any federally funded contract, makim; any federally funded grain or loan, entering iiuo any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded contract, giant, loan, or cooperative agreement.

Page 9 of L?

.V '["lie Disclosing Parly will submit an updated eertii'icaiion at (he end of each calendar quarter in which there occurs any event thai materially ;ifleets the accuracy of the statements and information set forth in paragraphs A.l. and A.l. above.

The Disclosing Party certifies lhal either: (i) il is not an organization described in section 5111(c)(4) of ihe Internal Revenue Code of 1986: or (ii) it is an organization described in section 501(c)(4) of ihe Inlernal Revenue Code of I9K6 but has not engaged and will not engage in "Lobbying Activities".
11" ihe Disclosing Party is ihe Applicant, llic Disclosing Party must obtain certifications equal in form and substance lo paragraphs A.l. through A.4. above I'rorn all subcontractors before it awards any subcontract and the Disclosing Parly must maintain all such subcontractors' certifications for die duration of ihe Mailer and must make such certifications promptly available lo the City upon request.

13. CERT1FICA IION REGARDING EQUAL EM PLOYM ENT OPPORTUNITY

If the Mailer is federally funded, federal regulations require the Applicant and all proposed subcontractors lo submit the following information with their bills or in writing at the outset of negotiations.

Is ihe Disclosing Parly ihe Applicant?

| | Yes I 1 No

11" "Yes,"' answer Ihe three questions below:

Have you developed and do you have on file affirmative action programs pursuant lo applicable federal regulations? (See 4 I CFR Part 60-?')

L J Yes [ j No

I lave you filed wilh the Joint Reporting Committee, the Direclor of Ihe Office ol" Eederal Contract Compliance Programs, or ihe Equal Employmenl Opportunity Commission all reports due under the applicable filing requirements?

| | Yes " I' | No

v Have you purlicipaied in any previous contracts or subcontracts subject lo ihe equal opportunity clause?

I. 1 Yes | | No

If you cheeked "\'o" to question I. or 2. above, please provide an explanation:

Page ID of Ii

SUCTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COM PLIANCE. PENALTIES, DISCLOSURE

l"lic Disclosing Parly understands and agrees thai:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contractor other agreement between ihe Applicant and the City in connection wilh the Mailer, whether procurement. Cily assistance, or oilier Cily action, and are material inducements lo ihe City's execution of any contract or Inking oilier action wilh respect lo ihe Mailer. The Disclosing Parly understands lhal it must comply wilh all slalutes, ordinances, and regulations on which this LDS is based.

H. The City's Governmental Ethics and Campaign Financing Ordinances. Chapters 2-156 and 2-164 of ihe Municipal Code, impose certain duties and obligations on poisons or entities seeking Cily contracts, work, business, or transactions. The full lext of these ordinances and a training program is available on line at w w w, c i ly o r'c h i c a go, o riz.'Tl t h i cs, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (3)2) 744-9660, The Disclosing Parly must comply fully with ihe applicable ordinances.

C. II" the City determines lhal any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which il is submitted may be rescinded or be 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 Party's participation in the Mailer and/or declining lo allow the Disclosing Parly lo participate in other transactions wilh the City. Remedies at law for a false statement of material fact may include incarceration and an award lo the City of Ireblc damages.

1). ll is the City's policy to make litis document available to Ihe public on its Internet site and/or upon request. Sonic or all of the information provided on this EDS and any filiachinenls lo this EDS may he made available lo the public on ihe Internet, in response lo a Freedom of Information Acl request, or otherwise. By completing and signing this EDS, ihe Disclosing Party waives and releases any possible rights orclaims which il may have against ihe City in connection with the public release of in formation contained in this EDS and also authorizes ihe City to verify the accuracy of any information .submitted in this EDS.

E. The information provided in this EDS must be kept current. In Ihe event of changes, the Disclosing Parly mtisl supplement this EDS up to the lime the Cily takes action on the Matter. Ifthe Mailer is a contract being handled by the Cily's Department of Procurement Services, the Disclosing Party musl update this EDS as ihe contract requires. NOTE: Willi respcel lo Manors subject lo Ariicle I ol" Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY lor certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as icquircd by Chapter I -23 ami Section 2-154-020 of the Municipal Code.

I he Disclosing Party repiesenis and warrants that'

Page I I of 13

I⁷.1. The Disclosing Parly is not delinquent in the payment of any lax administered by the Illinois Department of Revenue, nor are Ihe Disclosing Parly or iIs Affiliated Eniiues delinquent in paying any fine, fee, tax or olher charge owed to the Cily. This includes, but is nol limited to. all waier charges, sewer charges, license fees, parking liekels. properly taxes or sales taxes.

I-'.2 1 f the Disclosing Parly is the Applicant, ilie Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by ihe U.S. li.P.A. on ihe federal Excluded Parlies List System ("LPLS") maintained hy the I). S. General Services Administration.

F.3 Ifthe Disclosing Parly is ihe Applicant, ihe Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection wilh the Mailer certifications equal in form and substance to those in F.l. ami F.2. above and will not, wiihoni the prior written consent of (he City, use any such contractor/suhconlniclor that does nol provide- such certifications or that Ihe Disclosing Party has reason to believe has nol provided or cannot provide truthful certifications.

NOTE: If ihe Disclosing Parly cannot certify as to any of the items in E. 1., E.2. or F.3. above, an explanatory statement must be attached lo this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants thai he/she is authorized to execute ihis EDS and Appendix A (if applicable) on behalf of Ihe Disclosing Party, and (2) warrants lhal all certifications and statements contained in ihis EDS and Appendix A (if applicable) are true, accurate and complete as of the dale furnished lo the Cily.

^oW-LM.Lev'in

(.Print or type name of person signing)

Trustee,

(Print or lypc litle of person signing)

Signed and sworn to before me on (date) Jv/y" IXj 2013

^:'l _.£e>.4>l<. <- ^1111111 ^v ml (slate).

Notary Public.

OFFICIAL SEAL MARIANNE GORMAN Notary Public-State otIllinois

My Comrrtesior^x^

Commission expires: £A/t2£/o?6/3

I'.lliC I of I '>

CITY OF ("HICAC.'O ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVI T

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELEC TED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is lo he completed only by (it) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent, ll is not lo be completed by any legal entity which has only an indirect ownership interest in (he Applicant.

Under Municipal Code Section 2-154-015. the Disclosing Parly rnusl disclose whether such Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof'currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if. as of the dale this EDS is signed, the Disclosing Parly or any "Applicable Party" or any Spouse or Domestic Partner thereof is related lo ihe mayor, any alderman, the cily clerk, the city treasurer or any city department head as spouse or domestic partner or as any of die following, whelhcr by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, faiher-in-law, mother-in-law, son-in-law, daughter- in-law. stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sisler.

"Applicable Party" means (I) all executive officers of Ihe Disclosing Parly listed in Section ll.B. I .a., if the Disclosing Party is a corporation;.all partners of ihe Disclosing Parly, if ihe Disclosing Parly is a general partnership; all general partners and limited partners of the Disclosing Party, if (he Disclosing Party is a limited partnership; all managers, managing members and members of ihe Disclosing Party, ifthe Disclosing Parly is a limited liability company: (2) all principal officers of the Disclosing Party; and (3) any person having more lhan 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 ihe Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof currently have a "familial relationship" wilh an eleeled city official or department head?

I ] Yes piJ No

if yes. please identify below (I) the name and title of such person, (2) the name of ihe legal entity to which such person is connected: (3) the name and tide of (he elecied city official or department head to whom such person has a familial relationship, ami (4) Ihe precise nature of such familial relationship.

Page 13 of I .1

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

LfrTS X o Qy»/\<rry ST

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

[ ] 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:,

3. [ ] a legal entity with a right of control (see Section II.B.I.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: ■

Telephone: Fax: Email:
Name of contact person:
Federal Employer Identification No. (if ybu 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):

G. Which City agency or department is requesting this EDS?

Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Vcr. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

[ ] Person [ ]

[ ] Publicly registered business corporation [ ]

[ ] Privately held business corporation [ ]

[ ] Sole proprietorship [ ]

[ ] General partnership (Is

[ ] Limited partnership

>£ Trust [ ]

Limited liability company

Limited liability partnership

Joint venture

Not-for-profit corporation

the not-for-profit corporation also a 501(c)(3))?

[ ] Yes [ ] No

Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No [ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Ifthe entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

A3 TgOS-rtclZ-

Page 2 of 13

interest of a member or manager in a limited liability company,'or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-1 54-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the

Disclosing Party

S\JLl£ A- /-AtSkc

D 1^^c!^n£>^->t3 CVfidW_f ^1 6>Q6*t3k. of -rue. geti&ftcAPjes

kHt_L.|A-/>-\ A . LCtTS^ AArT p<Xt=t> /^*> C/t^tJQ-T

per AfceKrw-'^'O

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes fj^No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship (s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship lo Disclosing Party Fees (indicate whether

retained or anticipated Address t subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "houily rale'* or "t.b.d." is

nol an acceptable response.

(Add sheets if necessary)

f)(] Check here if ihe Disclosing Party has not retained, nor expects to retain, any such persons or enlilies. SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-°2-415, substantial owners of business entities that contract with the Cily must remain in compliance wilh their child support obligations throughout die contract's term.

Has any person who directly or indirectly owns 10% or more of the Disclosing Parly been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ J Yes No I j No person directly or indirectly owns 10% or more of ihe

Disclosing Parly.

If "Yes." has the person entered into a court-approved agreement for payment of all support owed and is ihe person in compliance with that agreement?

| | Yes f 1 No

13. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1 -23. Article I ("Article r*)(which the Applicant should consult for defined terms (.e.g "doing business") and legal requirements), ifthe Disclosing Party submitting this EDS is the Applicant and is doing business wilh ihe Cily, then the Disclosing Party certifies as follows: |i) neither ihe Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of. or has ever been convicted of. or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the Cily or any sister agency; and (ii) ihe Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing Easiness with the City. NOTE: If Anicle I applies to the Applicant, the permanent compliance timeframe in Ariicle I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

1'hc Disclosing Parly aiul. if ihe Disclosing Party is a legal eniily. all of those persons or enlilies identified in Section ll.li.l. of this EDS:

are not presently debarred, suspended, proposed for dehannciil. declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS. been convicted of a criminal offense, ad judged guilty, or had a civil judgment rendered against ihem in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction: a violation of federal or stale antitrust statutes; fraud; embezzlement: theft; forgery: bribery; falsification or destruction of records: making false statements; or receiving stolen property;

e. are not presently indicted for. or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B 2.b. of lhis Section V;

1. have not, within a five-year period preceding the dale of this EDS, hail one or more public transactions (federal, state or local) terminated for cause or default: and
2. have not, within a five-year period preceding the date of lhis 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 Cily or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concern:

lhc 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 enlilies 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, wilh ihe Disclosing Party, under common control of another person or eniily. 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 wilh federal or state or local government, including the Cily. using substantially the same management, ownership, or principals as lhc ineligible entity): wilh respect to Contractors, the term Affiliated Entity means a person or entity lhal directly or indirectly controls lhc Contractor, is controlled by it, or, wilh the Contractor, is under common control of another person or entity;

any responsible official of the Disclosing Parly, any Contractor or any A ["filiated lintity or any oilier official, agent or employee of the Disclosing Parly, any ('ontrnctor or any A ffilialed Enliiy. acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any AlTiliaicd Entity (colleelivelv "Agents").

Page 5 of 13

Neither lhc Disclosing Party, nor any Contractor, nor any AlTiliaicd Eniily of either the Disclosing Parly or any Contractor nor any Agents have, during the five years before ihe date this EDS is signed, or, with respect lo a Contractor, an Affiliated lintity. or an AlTiliaicd Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's eonlract or engagement in connection with the VI a Iter:

1. bribed or attempted to bribe, or been convicted or adjudged guilly uf bribery or attempting to brihe. a public officer or employee of Ihe City, the Slate of Illinois, or any agency of the federal government or of any state or local government in ihe United Stales of America, in lhal officer's or employee's official capacity:
2. agreed or colluded wilh oilier 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
3. made an admission of such conduct described in a. or b. above thai 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).

Pane 6 of 13

Neither the Disclosing Party. Affiliated lintity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rolating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any stale or of the United Stales of America thai contains ihe same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any AlTiliaicd Entity is listed on any of die following lists maintained by the Office of Foreign Assets Control of ihe U.S. Department of ihe Treasury or ihe 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, ihe Entity List and the Debarred List.
Fhe Disclosing. Parly understands and shall comply wilh ihe applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify lo any of the above statements m this Pari 13 (Funher Certifications), the Disclosing Parly must explain below:

If ihe loiters "NA," ihe word "None." or no response appears on lhc lines abo\c. il will he conclusively presumed lhal lhc Disclosing Party certified lo lhc above statements.

N. To ihe best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any lime during lhc I 2-monlh period preceding the execution date of lhis HDS, an employee, or elected or appointed official, of the City of Chicago Of "one, indicate wilh "N/A" or "none").

Mv hU- .; . .

o. To the best of the Disclosing Party's knowledge after reasonable inquiry, lhc following is a compleie list of all gills that the Disclosing Party has given or caused to be given, at any lime during the 12-monlh period preceding the execution date of lhis EDS, lo an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to lhc general public, or (ii) food or drink provided in lhc course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the Cily recipient.

.. vu.fci^

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies that the Disclosing Parly (check one)

[ 1 is r^l is not

a "financial institution" as defined in Section 2-32-455(b) of Ihe Municipal ('ode.

2, If lhc Disclosing Party IS a financial institution, ihen the Disclosing Party pledges:

"We are nol and will nol 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 ihcm 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 ihe loss of the privilege of doing business with the City."

If ihe Disclosing Party is unable to make lhis pledge because it or any of its affiliates (as defined in Section 2-32155(b) of the Municipal Code) is a predatory lender w ithin the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 1\

If the loiters "NA." ihe word "None." or no response appears on the lines aho\e. il will he conclusively presumed lhal ihe Disclosing Party certified lo the above statements.

D. CEKTI1TCA HON REGARDING INTERES T IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

In accordance with Section 2-1 56-110 ol" lhc Municipal Code: Docs any official or employee of lhc City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

['lYcs |)Q.No

NOTE: If you cheeked "Yes" to Hem D.I proceed to Items D.2. and D.3. 11 you checked "No" lo Item D.I 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 ihe purchase of any properly that (i) belongs to the City, or (ii) is sold Tor taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for properly taken pursuant to the City's eminent domain pow does nol constitute a financial interest within the meaning of this Part D.

Docs the Mailer involve a City Property Sale?

[ J Yes r ] No

If you ehecked "Yes" lo Item D.l., provide the names and business addresses of ihe Cily officials or employees hav ing such interest and identify the nature of such interest:

Name Business Address

N a lure of Interest

4. The Disclosing Parly further certifies lhal no prohibited financial interest in ihe Matter will he acquired by any City official or employee.

E. CER TiEICA HON REGARDING SLAVERY ERA BUSINESS

Please cheek cither I. or 2. below. If the Disclosing Party checks 2 the Disclosing Patty must disclose below or in an ailaclimcnl lo lhis EDS all information required by paragraph 2. Eailurc lo

Page S of 13

comply wilh these disclosure icquiremcnls may make any contract entered into with the Cily in connection w ith the Matter voidable by the City.

j<L_). The Disclosing Parly verities lhal the Disclosing Parly has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during lhc slavery era (including insurance policies issued to slaveholders that provided coverage for damage lo or injury or death of their slaves), and the Disclosing Party has found no such records.

2. T he Disclosing Parly verifies that, as a result of conducting the search in slop 1 above, ihe Disclosing Pany has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: Ifthe Matter is federally funded, complete this Section VI. Ifthe Matter is not federally funded, proceed lo 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. CERTIFICAT ION REGARDING LOBBYING

1. l ist 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 lo the Mailer: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or if the loners "NA" or ifthe word "None" appear, il will be conclusively presumed lhal the Disclosing Party means that NO persons or enlilies registered under the Lobbying Disclosure A el of 1995 have made lobbying contacts on behalf of the Disclosing Parly vvilh respect to ihe Mailer.)

2. The Disclosing Patty has nol spenl and will not expend any federally appropriated funds to pay any person or eniily listed in Paragraph A.l. above for his or her lobbying activities or lo pay any person or eniily 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 wilh ihe award of any federally funded contract, making any lederaEv funded grant or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded contract, grain, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies thai either: (j) il is not an organization described in section 501(c)(4) of the Internal Revenue ("ode of 1986; or (ii) it is an organization described in section 501(c)(4) of ihe Internal Revenue Code of 1986 but has nol engaged and will not engage in "Lobbying Activities".
If ihe Disclosing Party is ihe Applicant, lhc Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and lhc Disclosing Parly must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available lo the Cily upon request.

P». CHR niTCATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors lo submit ihe following information with ihcir bids or in writing ai the outset of negotiations.

Is the Disclosing Party the Applicant?

[ | Yes [ ] No

If' Yes,*' answer ihe three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

| | Yes' f J No

Have you filed with lhc Joint Reporting Committee, the Director of ihe Office of Federal Contract Compliance Programs, or Ihe Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

I j Yes I 1 No

.3. i lave you participated in any previous contracts or subcontracts subject to ihe equal opportunity clause?

I I Yes | | No

It"you cheeked "No" to question 1. or 2. above, please prov ide an explanation:

Page I Oof 13

SECTION VU - ACKNOWLEDGMENTS. CONTRACT INCORPORATION, COMPLIANCE, PENAL I JES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with Ihe Matter, whether procurement. City assistance, or other City action, and arc material inducements to the City's execution of any contract or taking other action wilh respect to the Matter. The Disclosing Party understands that il must comply with all slalules. ordinances, and regulations on which this EDS is based.

1). 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 Cily contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at w ww.citvofchicauo.orii/Ethic.s, and may also be obtained from the Cily's Hoard ol" Ethics, 740 N.

Sedgwick St., Suite 500, Chicago. IL 60610. (312) 744-9660. The Disclosing Party must comply fully with lhc applicable ordinances.

Ifthe City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies tinder the contract or agreement (it*nol rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Mailer and/or declining to allow the Disclosing Party lo participate in other transactions with ihe 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 Cily's policy lo make lhis document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or oiherwise. By completing and signing this EDS, ihe Disclosing Party waives and releases any possible rights or claims which it may have against lhc Cily in connection with ihe public release of information contained in lhis EDS and also auihoriv.es the Cily lo verify ihe accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, lhc Disclosing Party must supplement lhis EDS up to lhc lime the Cily lakes action on the Mailer. Il'lhc Mailer is a contract being handled by the Cily's Department of Procurement Services, ihe Disclosing Party must update this EDS as the contract requires. NO TE: Wilh respect lo Mailers subject lo Article I of Chapter 1-23 of ihe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-1 54-020 of ihe Municipal Code.

I he Disclosing Parly repicsculs and warrants thai:

Page 1 i of I I

F.l. The Disclosing Party is not delinquent in the payment of any tax administered hy the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, lax or other charge owed to ihe Cily. This includes, but is not limited to. all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 Ifthe Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will nol use. nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

1.3 Ifthe Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or lo be hired in connection with the Matter certifications equal in form and substance to those in F.l. ami F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does nol provide such certifications or that the Disclosing Parly has reason lo believe has nol provided or cannot provide truthful certifications.

NOTE: Ifthe Disclosing Party cannot certify as lo any of the items in F.l F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penally of perjury, the person signing below: (1) warrants that he/she is authorized to execute lhis EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) arc true, accurate and complete as of the date furnished to the City.

(Sign here)

(Prim or lypc name of person signing)

( Print or type title of person signing)

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected cily official or department head. A "familial relationship" exists if. as of the date this EDS is signed, the Disclosing Parly or any "Applicable Party" or any Spouse or Domestic Partner ther eof is related to lhc mayor, any alderman, the city clerk, the cily treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law. son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section lI.B.l.a., ifthe Disclosing Parly is a corporation; all partners of the Disclosing Parly, if Ihe Disclosing Party is a general partnership; all general partners and limited partners of lhc Disclosing Party, ifthe Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, ifthe Disclosing Parly is a limiledliability company; (2) all principal officers of the Disclosing Party: and {."") 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 lhc Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a familial relationship" with an elected cily official or department head?

| J Yes f^J;No

If yes. please identify below (1) the name and title of such person. (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected cily official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

[ ] 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:

3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: -

Telephone: Fax: Email:
Name of contact person:
Federal Employer Identification No. (if you have one): .
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable) :

G. Which City agency or department is requesting this EDS?

Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Vcr. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Part; Person

Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership Trust

\A Limited liability company [ ] Limited liability partnership [ ] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

[ ] Yes [ ] No

[ ] Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No ^N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Name Title

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-1 54-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the

Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[]Yes

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship (s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

Ifthe Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whelhcr Business Relationship In Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney. paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rale'' or "t.b.d." is

not an acceptable response.

( Add sheets if necessary)

^ Check here if ihe Disclosing Party has nol retained, nor expects lo retain, any such persons or enlilies SECTION V -- CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT" COMPLIANCE

Under M unieipal Code Section 2-92-41 5, substantial owners of business enlilies that contract with Mhe Cily must remain in compliance with their child support obligations throughout ihe contract's term.

[las any person who directly or indirectly owns 10% or more of lhc Disclosing Parly been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction'.'

[ J No person directly or indirectly owns 10% or more of lhc

Disclosing Parly.

If "Yes," has lhc person entered into a court-approved agreement for payment of all support owed and is lhc person in compliance wilh thai agreement?

[ | Yes f 1 No

13. FURTHER CERTIFICATIONS

1. Pursuant lo Municipal Code Chapter 1-23. Article I ("Article 1")(which lhc Applicant should consult for defined lerms (e.g., "doing business") and legal rci|uiremenis), if ihe Disclosing Parly submitting this EDS is the Applicant ami is doing business wilh the Cily, then the Disclosing Parly certifies as follows: (i) neither the Applicant nor any controlling person is currenlly indicted or charged with, or lias admitted guilt of, or has ever been convicted ol". or placet! undei supervision for, any criminal offense involving actual, ailcinpled, or conspiracy lo commit bribery, Ihefl, fraud, forgery, perjury, dishonesty oi doeeil against an officer or employee of the Cily or any sister agency: and (ii) the Applicant understands and acknowledges lhal compliance with Article I is a continuing rei|uirenient for doing business wilh lhc City. NO I E': If Article I applies to the Applicant. Ihe permanent compliance timeframe in Article I supersedes some live-year compliance timeframes in ucilificalions 2 and 3 below

Page lof 13

I'lio Disclosing Parly anil, if lhc Disclosing Parly is a legal eniily, all of those persons or enlilies identified in Section II.H.I. of this liDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government:
have nol, within a five-year period preceding the date of this HDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection wilh: obtaining, attempting lo obtain, or performing a public (Icdeinl, slale or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud: embezzlement; theft: forgery; bribery; falsification or destruction of records; making false statements: or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental eniily (federal, slate or local) wilh committing any of the offenses set forth in clause U.2.b. of this Section V:
have nol, wilhin a five-year period preceding the dale of lhis l-DS. 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 IiDS, been convicted, adjudged guilty, or found liable in a civjl proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by lhc City or by the federal government, any state, or any other unit of local government.
T he certifications in subparts 3. 4 and 5 concern:

- the Disclosing Parly;
any "Coniraclor" (meaning any contractor or subcontractor used by lhc Disclosing Parly in connection wilh the Mailer, including but not limited lo till persons or legal enlilies disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Panics");
any "Affiliated llntily" (meaning a person or entity that, directly or indirectly: controls lhc Disclosing Party, is controlled by the Disclosing Parly, or is, wilh the Disclosing Parly, under common control of another person or entity. Indicia of control include, without limitation:

inlet locking management or ownership: iileniily of interests among family members, shared facilities and equipment; common use of employees: or organization of a business entity following (he ineligibility of a business entity lo do business wilh federal or slale or local government, including the City, using substantially ihe same management, ownership, or principals as the ineligible eniily): with respect to Contractors, the term Affiliated l-ntity means a person or entity that direcily or indirectly controls the ('ontraclor, is controlled by il. or. with lhc Coniraclor. is under common control of another person or entity:

any responsible official of the Disclosing Parly, any Contractor or any Affiliated l-'niily or any other official, agent or employee of the Disclosing Party, any (.'ontraclor or any Affiliated lintity, acting pursuant lo the direction or authorization of a responsible official of the Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of i 3

Neither ihe Disclosing Party, nor any Contractor, nor any AlTiliaicd lintily of either ihe Disclosing Party or any Contractor nor any Agents have, during the five years before the dale this F.DS is signed, or, with respect lo n Coniraclor, an Affiliated Kiuity. or an Affiliated lintity of a Coniraclor during the five years before the date of such Contractor's or Affiliated F.nliiy's contract or engagement in connection wilh the Mailer:

1. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting 10 bribe, a public officer or employee of ihe City, the Stale of Illinois, or any agency of lhc federal government or of any stale or local government in ihe United Slates of America, in lhal officer's or employee's official capacity:
2. agreed or colluded wilh Oliver 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
3. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-d 10 ( Living Wage Ordinance).

Neither the Disclosing Party, AlTiliaicd Eniily or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of slate or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33F.-3; (2) bid-rotating in violation ol'72() ILCS 5/33ri~4: or (3) any similar offense of any slale or of the United Stales of America lhal contains the same elements as ihe offense of bid-rigging or bid-rolaling.
Neither the Disclosing Parly nor any AlTiliaicd lintity is listed on any of the following lists maintained by ihe Office ol" Foreign Assets Control of ihe U.S. Department of the Treasury or lhc Ikireau of Industry and Security of the U.S. Department of Commerce or their successors: die Specially Designated Nationals List, the Denied Persons List, the Unverified Lisi, ihe 17niiiy List and the Debarred List.

(->. flic 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 Fihics) of the Municipal C ode.

7. i 1"ihe Disclosing Parly is unable to certify to any of the above statements in lhis Pari H (Further Certifications), the Disclosing Parly must explain below:

|4/ k " _

Page o of 13

Ifthe loiters "NA." the word "None." or no response appears on the lines above, il wdl be conclusively presumed thai ihe Disclosing Party certified lo the above statements.

8. To lhc best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all current employees of lhc Disclosing Parly who were, at any lime during lhc I 2-month period preceding the execution date of this LiDS, an employee, or elected or appointed official, of lhc Cily of Chicauo (if none, indicate with "N/A" or ''none'").

"4.v4'i/_

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a

complete lisi of all gifts dial the Disclosing Parly has given or caused to be given, at any lime during the

12-monlh period preceding lhc execution date of this F.DS, lo an employee, or elected or appointed

official, of the Cily of Chicago. For purposes of lhis statement, a "gift" does not include: (i) anything

made generally available to Cily employees or lo 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 lo any gift listed below, please also list ihe name of the City recipient.

...vlotA-c- _ _

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Parly certifies that the Disclosing Party (check one)

| j is tf] is nut

a "financial institution" its defined in Section 2-32-'155(b) of the Municipal Code.

Ifthe Disclosing Party IS a financial inslilulion, then ihe Disclosing Party pledges:

"We are nol and will not become a predatory lender as defined in Chapter 2 32 of the Municipal ( ode. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of lhc Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ol'the privilege of doing business with the Cily."

If the Disclosing Party is unable lo make this pledge because it or any of its affiliates (as defined in Section 2-32-45'Hb) of the Municipal Code) is a predatory lender wilhin the meaning of Chapter 1- M of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of I:;

If lhc letters "NA." Ihe word "None," or no response appears on ihe linos above, il will be conclusively presumed thai the Disclosing I'arly certified lo the above statements.

D. CERTIFICATION REGARDING INTEREST IN CIT Y BUSINESS

Any words or terms that are defined in Chapter 2-1 56 of the Municipal Code have die same meanings when used in this Part D.

In accordance wilh Section 2-156-110 of the Municipal Code: Does any official or employee of the Cily have a financial interest in his or her own name or in the name of any oiher person or entity in I lie Mailer?

I I Yes [v^No

NOTE: If you checked "Yes" lo Item D. I proceed lo Items D.2. and D">. If you checked "No" lo Item 1). I., 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 properly thai (i) belongs to lhc Cily, or (ii) is sold for taxes or assessments, or (iii ) is sold by virtue of legal process at the suit of die City (collectively, "Cily Property Sale"). Compensation for property taken pursuant to lhc Cily's eminent domain power does not constitute a financial interest within ihe meaning of litis Part D.

Does the Mailer involve a City Property Sale?

f 1 Yes | j No

.1. If you checked "Yes" to Item D.l provide the names and business addresses of the City officials or employees having such interest and identify ihe nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies lhal no prohibited financial interest in the Matter will lie acqttiicd by any Cily official or employee.

E ('ERT'IHCATION REGARDING SLAVERY LRA BUSINESS

Please chock cither I, or 2. below. Ifthe Disclosing Patty checks 2 the Disclosing Parly must disclose below or in .in attachment lo this EDS all in foi malion required by paragraph 2. failure to

Page S I' ! »

comply wiih these disclosure rcquircmonis may make any conlraci entered inio wilh the Cily in conneclion wilh lhc Vlattcr voidable by Ihe City.

_vj I. The Disclosing Party verifies thai ihe Disclosing Parly has searched any and all recoids of

ihe Disclosing Parly and any and all predecessor enlilies regarding records of investments or profits from slavery or slaveholder insurance policies during lhc slavery era (including insurance policies issued lo slaveholders that provided coverage for damage lo or injury or death of their slaves), and lhc Disclosing Parly has found no such recoids.

2. The Disclosing Party verifies lhal. as a result of conducting the search in step I above, the

Disclosing Party has found records of invc.stme.nls or profits from slavery or slaveholder insurance policies. The Disclosing Parly verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those recoids:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VI. Ifthe Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the Cily 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 contacts on behalf of the Disclosing Parly wilh respect to lhc Matter: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or ifthe letters "NA" or if lhc word "None" appear, il will be conclusively presumed lhal the Disclosing Party means thai NO persons or entities registered under Ihe Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Parly wilh respect lo the Matter.)

2 The Disclosing Party has nol spent and w ill not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. I. above for his or her lobbying activities or to pay any person or eniily to influence oi attempt lo influence an officer or employee of any agency, as defined hy 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 awaid of any federally funded contract, making any federally funded grnnl or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded eoniracl. grant, loan, or cooperative agreement.

Page 9 of l.t

Ihe Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies lhal either: (i) it is nol an organization described in section 501(e)(4) of (he Internal Revenue Code of 1086: or (ii) il is an organization described in section 501(c)(4) of lhc Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
Ifthe Disclosing Parly is the Applicant, the Disclosing Parly must obtain certifications equal in 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 subcontractors' certifications for lhc duration of the Matter and must make such certifications promptly available lo lhc City upon request.

13. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

If Ihe Mailer is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing al lhc outset of negotiations.

Is the Disclosing Party Ihe Applicant?

f | Yes [ ] No

If "Yes," answer the three questions below:

Have you developed and do.you have on file affirmative action programs pursuant lo applicable federal regulations? (Sec 4 1 CFR Pari 60-2.)

I I Yes f 1 No

Have you filed wilh Ihe Joint Reporting Committee, the Director of the Office of Federal Conlraci Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements'?

r. I Yes [ ] No

Have you participated in any previous eoniraeis or subcontracts subject lo the equal opportunity clause?

f j Yes [ j No

I f you cheeked "No" to question I. or 2. above, please provide an explanation:

Page 10 of 13

SEC TION VTl - ACKNOWLEDGMENTS, CON TRACT INCORPORATION, COM I'LIANCE, PENALTIES, DISCLOSURE

The Disclosing Parly understands and agrees thai:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, Cily assistance, or other City action, and arc material inducements lo the Cily's execution of any contract or taking other action wilh respect lo Ihe Matter. The Disclosing Party understands that il must comply with all statutes, ordinances, and regulations on which lhis EDS is based.
The Cily'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 enlilies seeking City contracts, work, business, or transactions. The full text of ihcsc ordinances and a training program is available on line at w w vy. c i tyo Tc h i ca no. or n/E i h i c s, and may also be obtained from lhc City's Board of Ethics, 740 N.

Sedgwick Si 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 lhis EDS is false, incomplete or inaccurate, any contract or oilier agreement in connection with which it is submitted may be rescinded or bo void or voidable, and ihe City may pursue any remedies under lhc contract or agreement (if nol rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in lhc Matter and/or declining lo allow the Disclosing Party lo participate in other transactions with lhc City. Remedies at law for a false statement of material Tact may include incarceration and an award lo the City of treble damages.
Il is the Cily's policy to make this document available to the public on its Intcrncl site and/or upon request. Some or all of the information provided on lhis EDS and any attachments lo this EDS may be made available lo the public on the Internet, in response lo a Freedom of Information Act rcquesi, or otherwise. By completing and signing lhis EDS. die Disclosing Parly waives and releases any possible rights or claims which it may have against the Cily in conneclion u ilh lhc public release of information contained in this EDS and also authorises the Cily to verify the accuracy of any infoimaiion submitted in lhis EDS.
flic information provided in (his EDS must be kept current. In ihe event of changes, lhc Disclosing Parly must supplement this EDS up to the lime the Cily lakes action on ihe Matter. IT ihe Mailer is a conlraci being handled by ihe Cily's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: Willi respect to Mailers subject to Ariicle 1 of Chapter 1-23 of lhc Municipal Code (imposing PERMANENT INELIGIBILI TY for certain specified offenses), lhc information piovided herein regarding eligibility must be kept current Tor a longer period, .is required hy Chapter 1-23 and Section 2-1 54-020 of the Municipal Code.

I he Disclosing Party represents and warrants that:

Page 11 of 13

I-'.l. The Disclosing Party is nol delinquent in lhc payment of any tax administered by the Illinois Department or" Revenue, nor arc ihe Disclosing Party or its AlTiliaicd Enlilies delinquent in paying any fine. tee. tax or other charge owed to the City. This includes, bill is nol limited to, all water charges, sewer charges, license fees, parking lickels. property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Parly and ils Affiliated Entities will not use. nor permit their subcontractors lo use, any facility listed by the U.S. PP.A. on the federal Excluded Parties List System ("EPI.S") maintained by the U. S. General Services Administration.

I-.3 If ihe Disclosing Party is the Applicant, the Disclosing Parly will obtain from any contractors, subcontractors hired or to be hired in conneclion with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will nol, without ihe prior written consent of Ihe Cily, use any such contractor/subcontractor thai does not provide such certifications or lhal lhc Disclosing Party has reason lo believe has nol provided or cannot provide irulhlul certifications.

NOTE: If the Disclosing Parly cannot certify as to any of ihe items in F. I F.2. or F.3. above, an explanatory statement must be attached lo this EDS.

CERTIFICATION

Under penally of perjury, the person signing below: (1) warrants lhal he/she is authorized to execute lhis EDS and Appendix A (if applicable) on behalf of lhc Disclosing Party, and (2) warrants lhal all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of ihe date furnished to the City.

M ^,vi r MfrryftQc U-L

(Print or type nmctft Disclosing Party) ^lgn here)

fV\4iZ-t- H-U-*f1 -

(Print or type name ol*person signing)

(Print or type title of person signing)

/S2

( ommi.ssion expires:

Signed and sworn lo before me on (dale) ^:U -(jUQ County.

(slate).

Notary Public.

Pauc 12 of

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OFFICIAL SEAL NANCY TURKEN Notfcry Public - Stale of Illinois My Commission Expires Apr 1. 2017

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND-AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to he completed only by (a) the Applicant, and (h) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. If is not (o be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, die Disclosing Party must disclose whether such Disclosing Party or any "Applicable Parly" or any Spouse of Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if. as of die date ihis 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 cily clerk, the cily treasurer or any city department head as spouse or domestic partner or as any of (he following, whether by blood or adoption: parent, child, brother or sislcr. attnl or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law. daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or hall-sister.

"Applicable Party" means (1) all executive oUlcers of lhc Disclosing Party listed in Section II.B. I .a., if the Disclosing Parly is a corporation; all partners of lhc Disclosing Party, ifthe Disclosing Parly is a general partnership; all general partners and limited partners of the Disclosing Party, ifthe 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 Parly. "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 Parly or any "Applicable Parly" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ 1 Yes No

If yes. please identify below (I) Ihe name and lille of such person. (2) lhc name of the legal eniily to which Mich person is connected; (."?) the name and title of the clecled city official or department head lo whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page E) of I *

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

[ ] 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:,

3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: ■

Telephone: Fax: Email:
Name of contact person:
Federal Employer Identification No. (if you have one): .
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

G. Which City agency or department is requesting this EDS?

Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of the Disclosing Party:

Person ^ Limited liability company

Publicly registered business corporation [ ] Limited liability partnership

Privately held business corporation [ ] Joint venture

Sole proprietorship [ ] Not-for-profit corporation

General partnership (Is the not-for-profit corporation also a 501(c)(3))?

Limited partnership [ ] Yes [ ] No

Trust [ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No jl^N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Ifthe entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

Page 2 of 13

Name Business Address Percentage Interest in the

Disclosing Party

LJ-- Pop Pfr/zrrJiz&S LuC ^0$) H- fairer* XL- 6QfcM<^ ' S&'A

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[] Yes

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship (s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

Ifthe Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship lu Disclosing Parly Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) .NOTE:

to be retained) lobbyist, etc.) "hourly rale" or "l.b.d." is

nol an acceptable response.

(Add sheets if necessary)

(1], Check here ifthe Disclosing Party has nol retained, nor expects lo retain, any such persons or enlilies. SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-415, substantial owners ol" business enlilies that contract wilh the Cily must remain in compliance with their child support obligations throughout the contract's term.

Mas any person who directly or indirectly owns 10% or more of the Disclosing Parly been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

f j 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 lhc person in compliance with lhal agreement?

I I Yes [ ] No

B. FURTHER CERTIFICATIONS - -

I. Pursuant lo Municipal Code Chapter 1-23, Article I ("Article l")(which ihe Applicant should consult Tor defined terms (e.g "doing business") and legal requirements), iJ" the Disclosing Party submitting lhis EDS is the Applicant and is doing business wilh lhc 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 tinder supervision for, any criminal offense involving actual, attempted, or conspiracy lo commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of (he City or any sister agency: and (ii) the Applicant understands and acknowledges lhal compliance wilh Article I is a continuing requirement for doing business wilh the City. NOT E: If Article I applies lo the Applicant, the permanent compliance inuefianic in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

The Disclosing Party and. if the Disclosing Party is a legal entity, all of those persons or enlilies identified in Section II.B.l. of litis EDS:

1. arc nol presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any iransaciions by any federal, stale or local unit of government:
2. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil Judgment rendered against them in conneclion with: obtaining, attempting to obtain, or performing a public (federal, siaic or local) transaction or contract under a public transaction; a violation of federal or stale antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property,
3. arc nol presently indicted for, or criminally or civilly charged by. a governmental entity (federal, stale or local) wilh committing any of the offenses set forth in clause B.2.b. of this Section V;
4. have not. within a five-year period preceding the date of this EDS, had one or more public iransaciions (federal, slale or local) terminated for cause or default; and
5. have nol, within a five-year period preceding ihe 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 Cily or by the federal government, any slale, or any other unit of local government.
The certifications in subparts 3. 4 and 5 concern:

- the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by lhc Disclosing Party in connection with the Matter, including but not limited to all persons or legal enlilies disclosed under Section IV, "Disclosure ol"Subcontractors and Other Retained Parlies");
any "Affiliated Entity" (meaning n person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by ihe Disclosing Party, or is. with (he Disclosing Party, under common control of another person or entity. Indicia of control include, vvilhoul limitation: interlocking management or ownership; identity of inierests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following ihe ineligibility of a business eniily lo do business with federal or slale or local government, including the Cily. using substantially ihe same management, ownership, or principals as the ineligible entity): wilh respect lo Contractors, ihe term Affiliated Entity means a person or entity that directly or indirectly controls ihe Coniraclor. is controlled by it, or. wilh the Contractor, is under common control of another person or entity:
any responsible official of the Disclosing Parly, any Coniraclor or any Affiliated Eniily or any oilier official, agent or employee ol" ihe Disclosing Parly, any Coniraclor or any A ffiliated Emily, acting puisuanl to Ihe direction or authorization ofa responsible official of the Disclosing Parly, any Contractor or any Affiliated lintity (collectively "Agents").

Page S of 13

Neither ihe Disclosing Party, nor any ("ontraclor. nor any Affiliated Entity of either ihe Disclosing Party or any Contractor nor any Agents have, during ihe five years before the date this EDS is signed, or. wilh respect 10 a Contractor, an Affiliated lintity, or an Affiliated Entity of a Contractor during ihe five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection wilh ihe VI alter:

1. bribed or attempted lo bribe, or been convicted or adjudged guilly of bribery or attempting to bribe, a public officer or employee of ihe City, the State of Illinois, or any agency of (he federal government or of any stale or local government in lhc United States of" America, in that officer's or employee's official capacity;
2. agreed or colluded wilh other bidders or prospective bidders, or been a parly to any such agreement, or been convicted or adjudged guilly 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
3. made an admission of such conduct described in a. or b. above thai is a matter of record, but have not been prosecuted for such conduct; or
violated lhc provisions of Municipal Code Section 2-02-610 (Living Wage Ordinance).

A. Neither the Disclosing Party, Affiliated Entity or Coniraclor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of statu or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33G-3: (2) bid-rotating in violation of 720 1LCS 5/33E-4; or (3) any similar offense of any slale or of die United Stales of America thai contains the same elements as the offense of bid-rigging or bid-rotating.

Ncillier the Disclosing Parly nor any Affiliated Entity is listed on any of lhc following lists maintained by ihe Office of Foreign Assets Control of lhc U.S. Department of lhc Treasury or ihe Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons Lisi. the Unverified List, the Entity List and ihe 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 2-1 56 (Governmental Elhics) of (he Municipal Code.
If lhc Disclosing Party is unable lo certify lo any of the above statements in this Pari B (Further Certifications), ihe Disclosing Parly must explain below:

_ . ... .

Page 6 of H

It' the letters "NA," the word "None." or no response appears on the lines above, il will be conclusively presumed that the Disclosing Party certified lo the above statements.

X. To the best of lhc Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of ihe Disclosing Parly who were, at any time during the I 2-monlh period preceding ihe execution date of this EDS. an employee, or elected or appointed official, of the City of Chicago (if none, indicate wilh '"N/A" or "none").

9. To the best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a

complete lisl of all gifts that the Disclosing Party has given or caused lo be given, at any rime during the

1 2-month period preceding the execution date of" this EDS, to an employee, or elected or appointed

official, of lhc City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything

made generally available to Cily employees or to the general public, or (ii) food or drink provided in the

course of official Cily business and having a retail value of less than S20 per recipient (if none, indicate

wilh "N/A" or "none"). As to any gift listed below, please also list ihe name of the Cily recipient.

... H kklL _

C. CERTIFICATION OF ST A IDS AS FINANCIAL INSTITUTION

The Disclosing Parly certifies that the Disclosing Parly (check one)

| J is (Xj is not

a "financial institution" as defined in Section 2-32-455(b) of ihe Municipal Code.

If ihe Disclosing Parly IS n financial institution, then the Disclosing Party pledges:

"Wc arc not and will nol become a predatory lender as defined in Chapter 2-32 of ihe Municipal Code. We further pledge thai none of our affiliates is, and none ol'lheni will become, a predatory lend er as defined in ( hapier 2-32 ol lhc Municipal Code. Wc understand that becoming a prcdatorv lender or becoming an affiliate of a predatory lender may result in lhc loss of Ihe privilege of doing business with the Cily "

Ifthe Disclosing Party is unable to make this pledge because il or any of iis affiliates (as defined in Section 2-3 2 4 55(b) of the Municipal Code) is a predatory lender within lhc meaning of Chapter 2-32 of the Municipal Code, explain here (atiach additional pages if necessary):

Page 7 of I 3

If (lie loners "NA," the word "None," or no response appears on lhc lines above, it will be conclusively presumed that the Disclosing Parly certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms thai arc defined in Chapter 2-156 of the Municipal Code have lhc same meanings when used in lhis Pari D.

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or eniily in. the Matter?

I] Yes |fi;No

NOTE: If you checked "Yes" lo Hem D.l., proceed lo Items D.2. and Di. If you checked "No" to Item D.I., proceed to Pail E.

Unless sold pursuant lo a process of competitive bidding, or otherwise permitted, no Cily elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the Cily, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of ihe City (collectively, "Cily Properly Sale"). Compensation for properly taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a Cily Properly Sale?

flYcs [ | No

If you checked "Yes" to Item D.l., provide lhc names and business addresses of the Cily officials or employees having such interest and identity the nature of such interest:

Name Business Address Nalurc of Interest

"I. The Disclosing Parly further coililies lhal no prohibited financial interest in the Matter will ho acquired by any Cily official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please chock oithei I. or 2. below. If lhc Disclosing Party checks 2., lhc Disclosing Party must disclose below or to an attachment to this EDS all information requited by paragraph 2. Failure lo

Page X of Ij

comply wilh ihcsc disclosure requirements may make any conlraci entered into with the City in conneclion with the Matter voidable by the City,

\|^ I. The Disclosing Parly verities that the Disclosing Parly has searched any and all records of the DiscJosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued lo slaveholders that provided coverage for damage lo or injury or death of their slaves), and lhc Disclosing Party has found no such records.

2. The Disclosing Parly verifies that, as a result of conducting lhc search in step 1 above, the

Disclosing Parly has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MA TTERS

NOTE: If the Matter is federally funded, complete this Section VI. Ifthe Matter Is not federally funded, proceed lo Section VII. Tor purposes of this Section VI, lax credits allocated by the City and proceeds of debt obligations of lhc City arc not federal funding,

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under (he federal Lobbying Disclosure Acl of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Mailer: (Add sheds if necessary):

(If no explanation appears or begins on the lines above, or if die letters "NA" or if the word '"None" appear, il will be conclusively presumed that Ihe Disclosing Parly means that NO persons or enlilies registered under Ihe Lobbying Disclosure Acl of 1995 have made lobbying coniacis on behalf of" the Disclosing Party with respect to lhc Matter.)

2. The Disclosing Party has nol spent and will not expend any federally appropriated funds lo pay any poison or entity listed in Paragraph A.l. above for his or her lobbying activities or lo pay any person or eniily to influence or altempi lo influence an officer oi 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 wilh lhc award of any federally funded contract, making any federally funded grant oi loan, entering into any cooperative agreement, oi lo extend, continue, renew, amend, or modify any federally funded conlraci, grant, loan, or cooperative agreement.

Page 9 of I.)

3. The Disclosing Parly will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.

-I, The Disclosing Parly certifies thai cither: (i) it is not tin organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) il is an organization described itvseetion 501 (c)(4) of the Internal Revenue Code of 19X6 bin has nol engaged and will not engage in "Lobbying Activities".

5. If lhc Disclosing Party is the Applicant, the Disclosing Parly must obtain certifications equal in form and substance lo paragraphs A.l. through A.4. above from all subcontractors before il awards any Mibcomract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of ihe Mutter and must make such certifications promptly available to the City upon request.

B. CER 1 UTCATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Ifthe Mailer is federally funded, federal regulations require lhc Applicant and all proposed subcontractors lo submit the following information wilh their bids' or in writing at the outset of negotiations.

Is ihe Disclosing Party the Applicant?

I J Yes [ J No

If "Yes," answer ihe three questions below;

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 4 I CER Part 60-2.)

[ ] Yes I J No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Conlraci Compliance Programs, or the 'Equal Emplnymcnl Opportunity Commission all reports due under the applicable filing requirements?

I J Yes |. | No

Have you participated in any previous eonuacis or subeonlraels subject lo the equal opportunity clause?

I ] Yes | | No

If you checked "No"" to question I. or 2. above, please provide an explanation:

Page ID of 13

SECTION VII » ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COM I'LIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection wilh the Matter, whether procurement, Cily assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to lhc Matter. The Disclosing Parly understands that il must comply with all statutes, ordinances, and regulations on which this EDS is based.

Ii. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of lhc Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full texl of these ordinances and a training program is available on line ai www.cityofchicauo.oi-^'Ethics, and may also be obtained from the Cily's Hoard of Ethics, 740 N.

Sedgwick St., Suite 500. Chicago. IE 60610, (312) 744-9660. The Disclosing Party mtisl comply fully wilh the applicable ordinances.

11" the Cily determines ihnl any information provided in this EDS is false, incomplete or inaccurate, any contract or oihcr agreement in connection wilh which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under tho contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Parly's participation in Ihe Matter and/or declining to allow the Disclosing Patiy to participate in other transactions with the City. Remedies at law Torn false statement of material fact may include incarceration ami an award to the City of treble damages.
It is the City's policy lo make this document available to lhc public on its Internet site and/or upon request. Some or all of the information provided on lliis EDS and any attachments to this EDS may be made available lo ihe public on lhc Internet, in response lo a Freedom of Information Act request, or otherwise. 13y completing and signing (his EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against ihe City in conneclion wilh the public release of information contained in lhis liDS and also authorizes the Cily to verify the accuracy of any information submitted in this EDS.

E. The iiU'ormaiion provided in this EDS mux I be kept current. In the event of changes, the Disclosing

Parly nuisi supplement this EDS up lo the lime the City takes action on the Matter. If the Matter is a

conlraci being handled by the City's Department of Procurement Services, ihe Disclosing Parly mttsl

update this EDS as the conlraci requires. NOTE: With respect lo Mailers subject to Article I of

Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified

offenses), the information provided herein regarding eligibility must be kepi current for a longer period,

as icquircd by Chapter I -23 and Section 2-154-020 of the Municipal Code.

i he Disclosing Party repiescnis and warrants that:

Page I 1 of 13

IM. The Disclosing Party is not delinquent in the payment of any tax administered hy the Illinois Department of Revenue, nor are the Disclosing Parly or its Affiliated Entities delinquent in paying any fine, fee, lax or other charge owed to die Cily. This includes, but is not limited to, all waier charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If ihe Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will 1101 use. nor permit their subcontractors to use. any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("El'LS") maintained by the U. S. General Services Administration.

F.3 If lhc Disclosing Parly is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or lo be hired in connection with ihe Matter certifications equal in form and substance lo those in F.l. and F'.2. above and will not, without lhc prior written consent of the City, use any such contrncior/subcoiilractor that does not provide such certifications or that the Disclosing Party has reason lo believe has not provided or cannot provide truthful certifications.

NOTE: Ifthe Disclosing Party cannot certify as to any of the ileitis in F.L, F.2, or F,3. above, an explanatory statement must be attached lo this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he-'shc is authorized lo execute (his EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) arc true, accurate and complete as of the daic^Jiirnishcd to lhc Cily.

MF. .).\^^^/^^-.

(Print or type native ojwisclosing Party) (Sign here)

J^^rlt: ^^^/VT⁷

(Prinl or type name of person signing)

(Prim or type litlo of person signing)

Signed and sworn to before me on (date) 7

at _ toVj^_ County, (state). 1 ~ ~ ■ - - ■

OFFICIAL SEAL-

Notary Public. 1 NANCYTURKEN

1 Not&ry Public - state of Illinois

Com.niss.on expires:,. ^/.i/H , 1 ^ Commission Expires Apr I _?017

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) flic Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to he completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Parly or any "Applicable Pat ty" or any Spouse or Domestic Parmer thereof currently has a "familial relationship" wilh any elected cily official or department head. A "familial relationship" exists if, as of the date lhis EDS is signed, the Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, ihe city clerk, lhc cily treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law. moiher-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Parly lisled in Section ILB.l.a., ifthe Disclosing Parly is n corporation; all partners of the Disclosing Parly, ifthe Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Parly, if lhc Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Parly, if the Disclosing Parly is a limited liability company: (2) all principal officers of ihe 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 eniily or any person exercising similar authority.

Does ihe Disclosing Party or any "'Applicable Party" or any Spouse or Domestic Partner thereof currently have n "familial relationship" with an elected city official or department head?

[ 1 Yes

If yes, please identify below (I) lhc name and title of such person, (2) the name of ihe legal entity to which such person is connected; (3) lhc name and title of the elecied cily official or department head to whom such person has a familial relationship, and ( I) the precise nature of such familial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

L.r. M f PAY^rxJueA LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

[sj 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: fXM. STKVTk" "P #4'-, ? F.~vg_Ti-A L-LyJ,

OR '³

3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: ^\)% AJ ■ )-M'LV/)~"fo
Telephone: V S>. 7^r/l Vi S' ^ Fax: .^i Vj? .LibfZ Email: TdPfihK. (£' -Sw IM -LLC C6h^
Name of contact person: Tfc-'fc-lZ i | f\ A^7-"JC, ...,
Federal Employer Identification No. (if you have one):!

Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

Pl^MSh T)rvp.r>P^i^rr r->£r>i aiAa vv, ^ //??-//£7 d-sr/HT

Which City agency or department is requesting this EDS? l^V-feO

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract it

Vcr. Ol-fll-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

Person

Publicly registered business corporation

Privately held business corporation

Sole proprietorship

General partnership

Limited partnership

Trust

l^fXimited liability company

[ ] Limited liability partnership

[ ] Joint venture

[ ] Not-for-profit corporation

(Is the not-for-profit corporation also a 501(c)(3))?

[ ] Yes [ ] No

[ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[]Yes []No ^[ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. . List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

Name Title

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-1 54-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the

Disclosing Party

-T^cg tu-MszB-. ^ogol HalSteP

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes

If yes, please identify below the name(s) of such City elected official(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, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing I'arty l ecs (indicate whether

retained or anticipated Address (subcontractor, attorney. paid or estimated.) NOTE:

to be retained) lobbyist, etc.) 'hourly rale" or "t.b.d." is

not an acceptable response.

(Add sheets it' necessary)

PjjjChcck here ifthe Disclosing Parlv has not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS

COURT-ORDP.R1 D CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-415, substantial owners of business entities that conlraci wilh ihe City must remain in compliance with their child support obligations throughout the coniracl's term.

lias any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes I 1 No person directly or indirectly owns 10% or more of the

Disclosing Party.

If "Yes," has ihe person entered into a court-approved agreement for payment of all support owed and is the person in compliance with thai agreement?

[ ) Yes t i No

FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article 1"){ which the Applicant should consult for defined terms (e.g "doing business") and legal requirements), if Ihe Disclosing Party submitting this EDS is lhc Applicant and is doing business with the City, then the Disclosing Parly certifies as follows: (i) neither lhc Applicant nor any controlling person is currently indicted or charged wilh. or has admitted guilt of, or has ever been convicted of. or placed under supervision for. any erimimil offense involv ing actual, attempted, or conspiracy lo commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the Cily or any sister agency: and (ii) the Applicant understands and acknowledges that compliance wilh Article 1 is a continuing requirement for doing business \\ ilh the City. NO El*!: If Ariicle I applies lo the Applicant, ihe permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page I of 13

The Disclosing Party nnd. il' the Disclosing Party is a legal entity, all of those persons or entities identified in Section ll.B.l. of this EDS:

arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government:
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in conneclion with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction: a violation of federal or slate antitrust statutes; fraud; embezzlement; theft; forgery; bribery: falsification or destruction ol" records: making false .statements; or receiving stolen properly;
arc not presently indicted for. or criminally or civilly charged by. a governmental eniily (federal, state or local) wilh committing any of the offenses set forth in clause 13.2.b. of this Section V;
have nol. within a five-year period preceding ihe date of this EDS. had one or more public transactions (federal, slale or local) terminated for cause or default; and
have not, within a five-year period preceding the dale of this EDS, been convicted, adjudged guilly. or (bund liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the Cily or by the federal government, any slate, or any other unit of local government.
1. The certifications in subparts 3, 4 and 5 concern:

ihe Disclosing Party;
any "'Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection wilh the Matter, including but nol limited to all persons or legal entiiies disclosed under Section IV. "'Disclosure of Subcontractors and Other Retained Parlies"):

any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, wilh 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 follow ing lhc ineligibility of a business entity to do business with federal or state or local government, including the Cily. using substantially the same management, ownership, or principals as the ineligible emily); wilh respect to Contractors, the term Affiliated lintity means a person or entity that directly or indirectly controls the Coniraclor, is controlled by it, or. with the Contractor, is under common control of another person or entity:
any responsible official of the Disclosing Parly, any ("ontraclor or any Affiliated Emily or any oilier official, agent or employee of the Disclosing Parly, any Coniraclor or any Affiliated Entity, acting pursuant lo the direction or authorization of a responsible official of the Disclosing Parly, any Conliactor or any Affiliated Eniily (collectively "Agents").

Paue5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of cither the Disclosing Party or any Contractor nor any Agents have, during ihe five years before ihe dale lhis EDS is signed, or. wilh respect lo a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the dale of such Contractor's or A ffilialcd Entity's contract or engagement in conneclion with lhc .VI alter:

1. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting 10 bribe, a public officer or employee of the Cily. the State of Illinois, or any agency of the federal government or of any state or local government in the United States ol" America, in that officer's or employee's official capacity:
2. agreed or colluded wilh other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilly 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
3. made an admission of such conduct described in a. or b. above that is a matter of record, hut have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither lhc Disclosing Party, AlTiliaicd Entity or Contractor, or any ol*their employees, officials, agents or partners, is barred from contracting wilh any unit of stale or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33 E-4: or (3) any similar offense of any stale or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity Lisi and the Debarred List.

». The Disclosing Parly 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 M unicipai Code.

7. I ("lhc Disclosing Part}' is unable to certify lo any of the abo\c statements in (his Pari B (Further Certifications), lhc Disclosing Party must explain below:

s.i \_ .\. . '__

Page h of )i

If lhc letters "NA," the word "None." or no response appears on the lines above, it will be conclusively presumed that lhc Disclosing Tarty certified lo lhc above stiuemenis.

8. I'o the best of lhc Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of lhc Disclosing Parly who were, at any lime during the 1 2-month period preceding lire execution dale of this 1:DS. an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").

Sic Nit ; _ .

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a

complete list of all gifts that ihe Disclosing Party has given or caused to be given, al any lime during the

12-moiuh period preceding the execution date of this liDS, lo an employee, or elected or appointed

official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything

made generally available lo Cily employees or to ihe general public, or (ii) food or drink provided in the

course of official City business and having a retail value of less than S20 per recipient (if none, indicate

wilh "N/A" or "none"). As to any gift lisled below, please also list the name of ihe City recipient.

_NA> tot-- _

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that ihe Disclosing Parly (check one)

[ ) is fjjjs not

a "financial institution" as defined in Section 2-32-455(b) oflhe Municipal Code.

If ihe Disclosing Parly IS a financial institution, then ihe Disclosing Party pledges:

"We arc not and will nol become a predatory lender as defined in Chapter 2-32 oflhe Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. Wc understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in lhc loss of ihe privilege of doing business wilh lhc City."

If the Disclosing Party is unable lo make this pledge because it or any of its affiliates (as defined in Section 2-32-4.">5(h) of the Municipal Code) is it predatory lender vviihin lhc meaning of Chapter 2-12 oflhe Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

11' lhc loners "NA." the word "None," or no response appears on lhc lines above, it will be conclusively presumed thai the Disclosing Parly certified lo die above statements.

D. CERTIEICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same meanings when used in lhis Part D.

In accordance wilh Section 2-156-1 10 ol ihe Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes KjLNo

NOTE: If you checked "Yes" to Item D.l proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed lo Part li.

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no Cily elected official or employee shall have a financial interest in his or her own name or in lhc name of any other person or entity in the purchase of any properly that (i) belongs to lhc City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit oflhe City (collectively, "City Properly Sale"). Compensation for properly taken pursuant to the Cily's eminent domain power does not constitute a financial interest within the meaning of lhis Part D.

Does lhc Matter involve a City Property Sale?

[ ] Yes [ I No

.>. If you checked "Yes" lo llcm D.l provide the names and business addresses of the City officials or employees having such interest and identify ihe nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies thai no prohibited financial interest in the Mailer will be acquired by any City official or employee.

P CERT I PIC AT ION REGARDING SLAVERY ERA BUSINESS

Please check either I. or .'. below. If the Disclosing Parly checks 2 ihe Disclosing Parly must disclose below or in an attachment to this EDS all infoimalion required by paragraph 2. failure to

Page S <>f 1.5

comply wilh ihcsc disclosure requircmcnls may make any conirncl entered into with ihe Cily in conneclion wilh the Mailer voidable by the Cily.

)£- 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of ihe Disclosing Party and any and all predecessor enlilies regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders lhal provided coverage for damage to or injury or death of ihcir slaves), and the Disclosing Parly has found no such records.

2. The Disclosing Parly verifies that, as a result of conducting lhc search in step 1 above, lhc Disclosing Parly has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including ihe names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VI. Ifthe Matter is not federally funded, proceed to Section VII. For purposes of this Section VL tax credits allocated by Ihe City and proceeds of debt obligations of the Cily arc not federal funding.

A. CERTIFICATION REGARDING LOBBYING

I. List below the names of all persons or entities registered under lhc federal Lobbying Disclosure Act of 1 995 who have made lobbying contacts on behalf of the Disclosing Parly wilh respect to lhc Matter; (Add >heets if necessary):

(If no explanation appears or begins on ihe lines above, or if lhc letters "NA" or if lhc word "None" appear, ii \v ill be conclusively presumed lhal the Disclosing Party means lhal NO persons or enlilies registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Parly with respect to ihe Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. I. above for his or her lobbying activities or to pay any person or eniily lo influence oi attempt to influence an officer oi 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 conneclion with lhc award of any fedeially funded contract, making any federally funded grain or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded conlraci. grant, loan, or cooperative agreement.

Page 9 of 1."

The Disclosing Party will submit an updated certification at lhc end of each calendar quarter in which there occurs any c\cnl that materially affects the accuracy oflhe statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that cither: (i) it is nol an organization described in section 501 (c)(4) of the Internal Revenue Code of 1986; or (ii) il is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant. Ihe Disclosing Party must obtain certifications equal in form and substance lo 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 lhc duration oflhe Matter and must make such certifications promptly available to the City upon request.

B. CERTll 1CATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Ifthe Mailer is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their hids or in writing at the outset of negotiations.

Is lhc Disclosing Party lhc Applicant?

f 1 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 CER Part 60-2.)

[lYcs f ] No

Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or lhc Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

I I Yes f 1 No

Have you participated in any previous eoniraeis or subcontracts subject lo the equal oppoitunity clause?

[ I Yes ' I ] No

If you checked "No"" lo question I. or 2. above, please provide an explanation:

Page It) of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COM PLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the Cily in connection with the Matter, whether procurement. City assistance, or other Cily action, and arc material inducements to lhc Cily's execution of any contract or taking other notion with respect to the Matter. The Disclosing Paity understands thai it must comply with all statutes, ordinances, and regulations on which this EDS is based.

Ii. The C ity'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.cityofehic;tgo.org/Ethics, and may also be obtained from the City's Hoard of Ethics, 740 N.

Sedgwick St., Suite 500. Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection wilh which il is submitted may be rescinded or be void or v oidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law. or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. Hy completing and signing lhis EDS. the Disclosing Parly waives and releases any possible rights or claims which it may have against lhc City in connection with ihe public release of information contained in lhis EDS and also authorizes the¹ City lo verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, ihe Disclosing Party must supplement this EDS up lo the lime the City lakes action on the Matter. Ifthe Mailer is a eonttaet being handled by the Cily's Department of Procurement Services, the Disclosing Party must update ibis EDS as the conlraci requires. NOTE: With respect to Mailers subject to Article 1 of Chapter 1-23 oflhe .Municipal Code (imposing PERMANENT INELIGIBILITY fur certain specified offenses), the information provided herein regarding eligibility must be kept curienl for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

!'hc Disclosing Party leprescnls and warrants thai:

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!■".!. The Disclosing Party is nol delinquent in the payment of any lax administered by the Illinois Department of Revenue, nor are ihe Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee. tax or other charge owed to ihe Cily. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, properly taxes or sales laxes.

F.2 Ifthe Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will nol use. nor permit their subcontractors to use, any facility listed by lhc U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If lhc Disclosing Parly is the Applicant, lhc Disclosing Parly will obtain from any contractors/subcontractors hired or to be hired in connection wilh the Mailer certifications equal in form and substance lo those in F.l. and F.2. above and will not. without the prior written consent of the Cily, use any such comractor/subcontraclor that docs nol provide such certifications or dial the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Parly cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to lhis EDS.

CERTIFICATION

Under penally of perjury, the person signing below: (1) warrants that he/she is authorized lo execute lhis EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) arc (rue. accurate and complete as of ihe date furnished to the Cily,

ix- k.i.-- i ,\u.\uVjl<-^

(Print or type name ol person signing)

(Print or type title of person signing)

Signed and sworn to before nic on (dale) J"v*-"y. ^l5j 9S!sL

Ml (CooK /y -County, -^^[^'^^oi.t (slale).

Notary Public.

Commission expires: -V-l8- '5

OFFICIAL SEAL TERENCE W RASER NOTARY PUBLIC - STATE OF ILLINOIS MY COMMISSION EXPIRES:04/.18/15

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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECT ED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only hy (a) (he Applicant, and (h) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015. the Disclosing Party must disclose whether such Disclosing Party or any '"Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected cily official or department head. A "familial relationship" exists if, as of the date this EDS is signed, ihe Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related lo the mayor, any alderman, the cily clerk, the cily treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law. mother-in-law, son-in-law, daughter-in-law. stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers oflhe Disclosing Party listed in Section II.B.i.a ifthe Disclosing Party is a corporation; all partners of the Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners oflhe Disclosing Party, ifthe Disclosing Party is a limited partnership: all managers, managing members and members of the Disclosing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers oflhe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Parly. "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 Parly" or any Spouse or Domestic Partner thereof currently have a '"familial relationship" with an elected city official or department head?

I 1 Yes (\j No

If yes. please identify below (1) She name and title of such person, (2) the name of the legal entity lo which such person is connected: (3) ihe name and title of the elected city olficial or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

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Legislation Text

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