OFFICE OF THE MAYOR
CITY OF CHICAGO
RAHM EMANUEL
MAYOR
January 25, 2017
TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO
Ladies and Gentlemen:
At the request of the Commissioner of Fleet and Facility Management, I transmit herewith ordinances authorizing the execution of lease and use agreements.
Your favorable consideration of these ordinances will be appreciated.
Mayor
o
Very truly yours,
ORDINANCE
WHEREAS, the City of Chicago (the "City") is a home rule unit of government by virtue of the provisions of the Constitution of the State of Illinois of 1970, and as such, may exercise any power and perform any function pertaining to its government and affairs; and
WHEREAS, the City is the owner of the real property and improvements located at 2418 West Division Street, Chicago, Illinois, known as the West Town Neighborhood Health Center (the "Property"); and
WHEREAS, on July 1, 2012, the City and Erie Family Health Center, Inc., an Illinois not for profit corporation ("Erie") executed Lease No. 20253 (the "Lease") governing Erie's use of approximately 11,310 square feet of office and clinical space in the West Town Neighborhood Health Center (the "Original Space") for a term ending on July 1, 2019; and
WHEREAS, on October 1, 2015, the City and Erie executed a First Amendment to the Lease ("First Amendment"), which expanded the Original Space to include an additional 4,633 square feet of space (the "First Amendment Space"); and
WHEREAS, Erie has been awarded a Federal grant in the amount of $499,702 from the Health Resources and Services Administration ("HRSA"), an agency of the U.S. Department of Health and Human Services, to fund improvements to Erie's clinic; and
WHEREAS, in order to satisfy the conditions of the Federal grant, the City and Erie entered into a Second Amendment to the Lease ("Second Amendment"), which, among other things, (i) extended the term of the Lease to December 31, 2026, (ii) expanded the leasehold premises to include an additional 329 square feet of space (the "Second Amendment Space" and, together with the Original Space and the First Amendment Space, the "Premises"), and (iii) included certain additional provisions required by HRSA; and
WHEREAS, the Premises are depicted on Exhibit B attached hereto; and
WHEREAS, 4,000 square feet of the Premises will be improved using the HRSA grant funds (the "Project Area"), and the Project Area is depicted on Exhibit C attached hereto; and
WHEREAS, one of HRSA's requirements is to record a Notice of Federal Interest against the Property, acknowledging that the Project Area was improved with Federal funds and imposing certain use and disposition requirements; and
WHEREAS, the Notice of Federal Interest states that the Property may not be used for any purpose inconsistent with the grant program; may not be mortgaged or otherwise used as collateral without the written permission of HRSA; and may not be sold or transferred to another party without the written permission of HRSA; and
WHEREAS, in an attempt to limit the duration of the Federal interest, the City added a provision to the Notice of Federal Interest, stating that the Federal interest would terminate upon
the termination of the Lease; and
WHEREAS, the Notice of Federal Interest, as amended by the City, was attached as Exhibit C to the Second Amendment; and
WHEREAS, pursuant to an ordinance adopted on October 5, 2016, and published at pages 33813 through 33822 in the Journal of the Proceedings of the City Council for such date, the City Council authorized the execution of the Second Amendment; and
WHEREAS, the City and Erie executed the Second Amendment on November 8, 2016;
and
WHEREAS, HRSA subsequently informed Erie that the Notice of Federal Interest attached to the Second Amendment did not meet Federal requirements because it included a termination provision; and
WHEREAS, HRSA requires a continuing Federal interest in the Property without any specified expiration or release date; and
WHEREAS, the City understands that the Notice of Federal Interest will encumber the Property and will prohibit the use of the Project Area for any purpose other than a healthcare facility until HRSA relinquishes its Federal interest; and
WHEREAS, when HRSA determines that the Property is no longer needed for a healthcare facility, HRSA will authorize disposition of the Federal interest; and
WHEREAS, HRSA's disposition instructions will authorize or require Erie (and by extension the City, as owner of the Property) to do one of the following: (1) retain title to the Property without further obligation to the Federal government after Erie (or the City) compensates the Federal government for that percentage of the current fair market value of the Property attributable to the Federal share in the project; (2) sell the Property under guidelines provided by HRSA and pay the Federal government for that percentage of the current fair market value of the Property attributable to the Federal share in the project (after deducting actual and reasonable selling and fix-up expenses, if any, from the sales proceeds); or (3) transfer title to the Property to the Federal government or to an eligible third party provided that, in such cases, the City shall be entitled to compensation for its attributable percentage of the current fair market value of the Property; and
" WHEREAS, HRSA and Erie have acknowledged that Erie, as the recipient of the HRSA grant, is primarily responsible for meeting the requirements of the Federal interest; provided, however, if Erie defaults or is otherwise unable to continue operating the clinic, the City would be responsible for continuing such use or another use that is approved by HRSA, and if unable to do so, would have to compensate the Federal government for its attributable percentage of the current fair market value of the Property; and
WHEREAS, Erie's use of the Premises to provide health care services reduces the
burdens on government and serves the public interest; and
WHEREAS, the City and Erie wish to execute a Third Amendment to the Lease to replace the Notice of Federal Interest that was attached as Exhibit C to the Second Amendment with a Notice of Federal Interest that conforms with HRSA's requirements, and for other purposes as more fully set forth in the Third Amendment; now, therefore,
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1. The foregoing recitals are hereby adopted as the findings of the City Council.
SECTION 2. The City hereby consents to encumbering the Property with a continuing Federal interest in the Property. This approval is expressly conditioned upon the City and Erie entering into a Third Amendment to the Lease in substantially the form attached hereto as Exhibit A ("Third Amendment"). The Commissioner of the Department of Fleet and Facility Management (the "Commissioner"), or a designee of the Commissioner, is each hereby authorized, with the approval of the Commissioner of the Department of Public Health and the approval of the City's Corporation Counsel as to form and legality, to negotiate, execute and deliver the Third Amendment, the Notice of Federal Interest attached as Exhibit A to the Third Amendment, and such other supporting documents as may be necessary or appropriate to carry out and comply with the provisions of the Lease, as amended, with such changes, deletions, insertions, terms and provisions as the Commissioner deems appropriate.
SECTION 3. This ordinance shall take effect immediately upon its passage and approval.
THIRD AMENDMENT TO LEASE
THIS THIRD AMENDMENT TO LEASE (the "Third Amendment") is made and
effective as of , 2017 (the "Commencement Date") by and between CITY
OF CHICAGO, a Municipal Corporation and Home Rule Unit of Government (the "City" or "Landlord") and ERIE FAMILY HEALTH CENTER, INC., an Illinois not-for-profit corporation ("Tenant").
RECITALS
WHEREAS, on July 1, 2012, Landlord and Tenant executed Lease No. 20253 (the "Lease") governing Tenant's use of the Premises located in the West Town Neighborhood Health Center; and
WHEREAS, the West Town Neighborhood Health Center is located at 2418 West Division Street, Chicago, Illinois, PINs 16-01-229-040, -047, -048, and -049, (the "Property"); and
WHEREAS, on October 1, 2015, Landlord and Tenant executed the First Amendment to the Lease (the "First Amendment"); and
WHEREAS, Tenant has been awarded a Federal grant from the Health Resources and Services Administration ("HRSA"), an agency of the U.S. Department of Health and Human Services, to fund improvements to Tenant's clinic on the Premises; and
WHEREAS, in order to satisfy the conditions of the Federal grant, Landlord and Tenant executed the Second Amendment to the Lease (the "Second Amendment") on November 8, 2016; and
WHEREAS, one of HRSA's requirements is to record a Notice of Federal Interest against the Property, which was attached as Exhibit C to the Second Amendment; and
WHEREAS, HRSA subsequently informed the Tenant that the Notice of Federal Interest attached to the Second Amendment did not meet Federal requirements because it included a termination provision; and
WHEREAS, HRSA requires a continuing Federal interest in the Property without any specified expiration or release date; and
WHEREAS, HRSA and the Tenant acknowledge that the Tenant, as the grantee for the Federal grant, has the responsibility for the disposition of the Federal interest in the Property; and
WHEREAS, the Landlord and Tenant wish to execute this Third Amendment to replace the Notice of Federal Interest that was attached as Exhibit C to the Second Amendment with a Notice of Federal Interest that conforms with HRSA's requirements, and for other purposes as more fully set forth in this Third Amendment.
NOW THEREFORE, in consideration of the above recitals, and mutual promises, covenants, rights and obligations herein contained, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Landlord and Tenant mutually agree as follows:
Recitals and Terms of Art. The foregoing recitals are hereby incorporated into and made a part of this Third Amendment by this reference. All capitalized terms in this Third Amendment shall have the same meaning ascribed thereto in the Lease, unless otherwise provided herein.
Federal Interest. The Notice of Federal Interest attached as Exhibit C to the Second Amendment shall be replaced with the Notice of Federal Interest attached as Exhibit A hereto.
3. Tenant's Responsibility for the Federal Interest.
The Tenant, as the grantee organization for the Federal grant, acknowledges that Tenant bears the responsibility for the disposition of the Federal Interest in the Property, not the Landlord. At such point when Premises are no longer needed or used for its original purpose, the Tenant shall coordinate with HRSA and Tenant shall either:
Transfer the Federal Interest to a different property owned or operated by Tenant, and have the Notice of Federal Interest withdrawn from this Property; or
Pay back to HRSA its attributable percentage of the current fair market value of the Property, as determined by and in accordance with Federal law.
Tenant agrees to indemnify the Landlord against any and all amounts owed to the Federal government under the Federal grant and any losses related to the Federal grant.
Throughout the Term of the Lease, the Tenant shall maintain a depreciation schedule of the HRSA funded capital improvements in accordance with applicable Federal regulations and the terms and conditions of the Federal grant.
4. Incorporation into Lease No. 20253. This Third Amendment shall be incorporated into the Lease as executed by Landlord and Tenant on July 1, 2012, the First Amendment as executed on October 1, 2015, and the Second Amendment as executed on November 8, 2016. Unless otherwise expressly provided herein, all other provisions of the Lease, the First Amendment, and the Second Amendment shall remain in full force and effect and shall be applicable to this Third Amendment. Unless expressly provided herein, if there is a conflict between the terms and conditions of the Lease, the First Amendment, or the Second Amendment and the terms and conditions of the Third Amendment, the terms and conditions of this Third Amendment shall prevail.
Counterparts. This Third Amendment may be executed in multiple counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument.
[SIGNATURES APPEAR ON THE FOLLOWING PAGE]
IN WITNESS WHEREOF, the parties have executed this Third Amendment to Lease as of the day and year first above written.
LANDLORD:
THE CITY OF CHICAGO,
an Illinois Municipal Corporation and Home Rule Unit of Government
DEPARTMENT OF PUBLIC HEALTH
Commissioner
DEPARTMENT OF FLEET AND FACILITY MANAGEMENT
Commissioner
APPROVED AS TO FORM AND LEGALITY: BY: DEPARTMENT OF LAW
Chief Assistant Corporation Counsel Real Estate Division
ERIE FAMILY HEALTH CENTER, INC.,
an Illinois not-for-profit corporation
By:_ Name:
Its:
(SUB-EXHIBIT A)
State of I llinois Cook County
NOTICE OF FEDERAL INTEREST
On December 14, 2012, the Health Resources and Services Administration's Bureau of Primary Health Care awarded Grant No. C12CS25610 to Erie Family Health Center (Erie). The grant provides Federal funds for alteration and renovation of Erie Division Street and Teen Health Centers, the former site of the Chicago Department of Public Health West Town clinic located at 2418 W. Division St., Chicago, IL 60622-2940. Erie Division Street and Teen Health Centers provide primary health care services to 12,361 patients through over 54,000 patient visits annually, regardless of a patient's ability to pay. Through this project, Erie will demolish and renovate 4,000 square feet of the facility to include: 7 exam rooms, 1 larger treatment room, 1 lab, a waiting area with three registration stations, a centralized care station with a nurse and additional space for medical assistants, private consultation space adjacent to the waiting room, and offices for behavioral health, case management, and WIC services. The Health Center is located on the property described below in Cook County, State of Illinois:
Lots 19 through 29 in Block 8 in the Resubdivision of the South Part of Blocks 5, 6, 7 & 8 of Winslow & Jacobson's Subdivision of the Southeast % of the Northeast Va of Section 1, Township 39 North, Range 14, East of the Third Principal Meridian in Cook County Illinois.
Permanent Index Numbers: 16-01-229-040, 16-01-229-047, 16-01-229-048, and 16-01-229-049
Address: 2418 W. Division St., Chicago, IL 60622-2940
The Notice of Grant Award for this grant includes conditions on use of the aforementioned property and provides for a continuing Federal interest in the property. Specifically, the property may not be (1) used for any purpose inconsistent with the statute and any program regulations governing the award under which the property was acquired; (2) mortgaged or otherwise used as collateral without the written permission of the Associate Administrator, Office of Federal Assistance Management (OFAM), Health Resources and Services Administration (HRSA), or designee; or (3) sold or transferred to another party without the written permission of Associate Administrator, Office of Federal Assistance Management (OFAM), Health Resources and Services Administration (HRSA), or designee. These conditions are in accordance with the statutory provisions set forth in the Patient Protection and Affordable Care Act of 2010, Section 10503, P.L. 111-148, Title IV, Section 4101, Title 45 CFR part 74 or 92 (as appropriate), the HHS Grants Policy Statement, and other terms and conditions of award.
These grant conditions and requirements cannot be nullified or voided through a transfer of ownership. Therefore, advance notice of any proposed change in usage or ownership must be provided to the Health Resources and Services Administration (HRSA), Office of Federal Assistance Management (OFAM).
Signature of Property Owner:
Typed Name:
Title:
Date:
On this the day of , 2017, before me the undersigned, a Notary Public for the State
Illinois at Large, personally appeared before me and is known to be the person who executed this instrument on behalf of the City of Chicago.
Witness my hand and official seal.
SWORN AND CONFIRMED TO BEFORE ME THIS DAY OF
, 20
Signature of Notary Public
County / State
My Commission Expires (Date)
Notary Seal:
EXHIBIT B The Premises
Shown as shaded area
N. WESTERN
EXHIBIT C The Project Area
Shown as shaded area
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 -- GENERAL INFORMATION
A. Legal name of the Disclosing
?arty submitlingjjds EDS. Include d/b/a/ if applicable:
fattier (m<62, Tjtc¦
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: 1 r^J>$^thc Applicant OR
2. [ ] 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:
OR
3. [ ] a legal entity with a right of control (see Section II.13.1.) Stale the legal name of the entity in
which the Disclosing Party holds a right of control:
\10\ 1/vJ- 6ufefr01c.
Q-TirA(?.n 7L £
C
Telephone: (nkttM^ (3 ^C^^j^ (hf^
D. Name of contact person: ^fi \/( D 2t-NP -
—*v r -
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):
Extension of lease term for lease of City-owned property located at 2418 W. Division St.
Which City agency or department is requesting this EDS? PepL of Fleet & Facility Management
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract U
Page 1 of 13
SECTION II.-- DISCLOSURE OF OWNERSHIP INTERESTS _ " "
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Parly:
[ ] 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 vf Yes [ ] No
[ ] Trust [ ] Oilier (please specify)
2. For legal entities, the stale (or foreign country) of incorporation or organization, if applicable:
3. For legal entities not organized in (he State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[ ] Yes [ ] No jX(N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which arc legal entities. If there arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal titlcholdcr(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership 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
U£.}(i:^Qh. ymimtc _ ivo S^c0
fe/W MmeUrft Qa-£MMI Zr)M (j^KDAi
M^a(\ ^oro \]\(iGmm*f- BMcf(k3-
fuc TwfrOA Itievmtfi
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 Parly. 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 bencficiary 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 IN - 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>4No
If yes, please identify below the namc(s) of such City elected official(s) and describe such relationship(s):
SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Parly 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 Parly is not required to disclose employees who arc paid solely through the Disclosing Parly's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profil 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 retained or anticipated Address to be retained)
Relationship t<)J?i"s^T6^ihg~Part"yI (subcontractor, attorney, lobbyist, etc.)
.. Fees (indie ale" wheth c r paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.
(Add sheets if necessary)
yf^C-'hcck here if the Disclosing Parly has not retained, nor expects to rclain, any such persons or entities. SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [ ] No J^Cl^0 Pcrson directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes," has the pcrson entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[ ] Yes
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if ihe 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 pcrson 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 J 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 Parly and, if the Disclosing Party, is a.lcgaTcffl identified in Section Il.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 ihcm 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 antilrusl statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, ad judged 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 pcrson or entity that, directly or indirectly: controls Ihe Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another pcrson 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 pcrson or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another pcrson or entity;
any responsible official of the Disclosing Parly, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither' the Disclosing Party, nor any Contractor, nor any Affiliated Entity of cither the Disclosing 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 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 slate or local government in the United Slates of America, in that officer's or employee^ official capacity;
agreed or colluded with other bidders or prospective bidders, or been a parly to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (I) bid-rigging in violation of 720 LLCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any stale or of the United Slates 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.
Page 6 of 13
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Parly must explain below:
IT 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 City of Chicago (if none, indicate with "N/A" or "none").
9. To the best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Parly has given or caused to be given, at any time during the 12-month period preceding the execution dale of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than 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 J^Cif not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
Page 7 of 13
If the Disclosing Party is unable to make this pledge because il 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):
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Parly certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-1 10 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 Jk^°
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Ttcm 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 pcrson or entity in the purchase of any properly that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power docs not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes J^No
If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify 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 1. oi 2. below. If the Disclosing Pally 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 disclosiircrcquirci^ City in
connection with the Matter voidable by the City.
1. The Disclosing Party verities that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Parly has found no such records.
2. The Disclosing Parly verifies that, as a result of conducting the search in step 1 above, the
Disclosing Parly has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing 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 records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, lax credits allocated by the City and proceeds of debt obligations of the City arc not federal funding.
A. CERTIFICATION REGARDING LOBBYING
List below (he names of all persons or entities registered under the federal Lobbying Disclosure Act of 1 995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
=-:Z^^~ |910|(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Parly means 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.)
The Disclosing Parly has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any pcrson 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
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?
Ml'es
If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
t J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[]No
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
KXYes \ ] No
If you checked "No" to question I. 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 arc material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-1 56 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.cilyofchicago.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 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 Parly represents and warrants that:
Page 1 1 of 13
F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor arc the Disclosing 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 docs not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3 - above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the pcrson signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) arc true, accurate and complete as of the dale furnished to the City.
/^e-tfl wy^i, fWlfw 6H't~V
r type-name of Disclos-nW Party)
(Print or type title of person signing)
Signed and sworn to before me on (dale) ^1 "9~^f j J2-Q{ jo ,
at (3 County, / /^/-v. (Vol .S '(slate).
!/ j NOTARY PUBLIC, STATE OF ILLINOIS
Commission expires: ' /B> ^ %5\ Q-oCj, V!^^^^^^.
Page 12 of 13
CITY OF CHICAGO KCONOMIC 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 Parly" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the dale this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., if the Disclosing Parly is a corporation; all partners of the Disclosing Party, if die Disclosing Parly is a general partnership; all general partners and limited partners of the Disclosing Parly, 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 pcrson having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any pcrson exercising similar authority.
Docs the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected cily official or department head?
[ ] Yes
If yes, please identify below (J) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
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 (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
I. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ ]Yes
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
I ]No
3. If yes to (1) or (2) above, please identify below the name of the person or legal entity
identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of (his page is for you to recertify your EDS prior to submission to City Council or on the dale of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This recertification is being submitted in connection with jJo^U Of QftCfKX Wc&Sf ^id^AW
[identify the Matter]. Under penalty of perjury, the pcrson signing below: (1) warrants that "
he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
arc true, accurate and complete as 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.
£ftf£ {amiix %H/M ( SMtbrl ^Wj.
(Print or type legal name of Disclosing Party)
Print or type name of signatory:
Us frifl,va^
Title of signatory:
olary Public.
Signed and sworn to before me on
* t *~ P^r>N (Lt €> , at Q.Q o K County, ( /-/-t t
Commission expires: /\V^ [ %S / V-OtJ
\ 'Gi+ICiAI-SrAL" I MARjA.I.ROCHA
\ no m>: public, s mi or Illinois