OFFICE OF THE MAYOR
CITY OF CHICAGO
RAHM EMANUEL MAYOR
July 28, 2011
TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO
Ladies and Gentlemen:
At the request of the Commissioner of the Environment, I transmit herewith an ordinance authorizing an amendment to the District Cooling System Use Agreement with Thermal Chicago Corporation.
Your favorable consideration of this ordinance will be appreciated.
Very truly yours,
Mayor
ORDINANCE
WHEREAS, on the 14th day of September, 1994, the City Council (the "City Council") of the City of Chicago, Illinois (the "City") adopted an ordinance authorizing the City to enter into a "District Cooling System Use Agreement" (the "Originaf Agreement") with MDE Thermal Technologies, Inc. (formerly Exelon Thermal Technologies, Inc. and formerly before that Unicom Thermal Technologies, Inc. and formerly before that Northwind, Inc., and referred to herein as "Grantee"), which grants to Grantee the non-exclusive right to use certain public ways of the City to construct, operate and maintain a district cooling system (the "System"); and
WHEREAS, the City and Grantee entered into the Original Agreement as of October 1, 1994; and
WHEREAS, on the 17th day of May, 1995, the City Council adopted an ordinance authorizing the City to enter into a "First Amendment to District Cooling System Use Agreement" (the "First Amendment"); and
WHEREAS, the First Amendment is dated as of June 1, 1995; and
WHEREAS, on the 13th day of July, 1995, the City Council adopted an ordinance authorizing the City to enter into a "Second Amendment to District Cooling System Use Agreement" (the "Second Amendment"); and
WHEREAS, the Second Amendment is dated as of July 15, 1995; and
WHEREAS, on the 10 day of January, 1996, the City Council adopted an ordinance authorizing the City to enter into a "Third Amendment to District Cooling System Use Agreement" (the "Third Amendment"); and
WHEREAS, the Third Amendment is dated as of February 1, 1996; and
WHEREAS, on the 6thday of March, 1996, the City Council adopted an ordinance authorizing the City to enter into a "Fourth Amendment to District Cooling System Use Agreement" (the "Fourth Amendment"); and
WHEREAS, the Fourth Amendment is dated as of April 1, 1996; and
WHEREAS, on the 16th day of April, 1996, the City Council adopted an ordinance authorizing the City to enter into a "Fifth Amendment to District Cooling System Use Agreement" (the "Fifth Amendment"); and
WHEREAS, the Fifth Amendment is dated as of October 1, 1996, and
WHEREAS, on the 30th day of October, 1996, the City Council adopted an ordinance authorizing the City to enter into a "Sixth Amendment to District Cooling System Use Agreement
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(the "Sixth Amendment"); and
WHEREAS, the Sixth Amendment is dated as of November 7, 1996; and
WHEREAS, on the 11th day of December, 1996, the City Council adopted an ordinance authorizing the City to enter into a "Seventh Amendment to District Cooling System Use Agreement" (the "Seventh Amendment"); and
WHEREAS, the Seventh Amendment is dated as of January 15,1997; and
WHEREAS, on the 7th day of February, 1997, the City Council adopted an ordinance authorizing the City to enter into an "Eighth Amendment to District Cooling System Use Agreement" (the "Eighth Amendment"); and
WHEREAS, the Eighth Amendment is dated as of May 1, 1997; and
WHEREAS, on the 30th day of July, 1997, the City Council adopted an ordinance authorizing the City to enter into a "Ninth Amendment to District Cooling System Use Agreement" (the "Ninth Amendment"); and
WHEREAS, the Ninth Amendment is dated as of August 1, 1997; and
WHEREAS, on the 10th of September, 1997, the City Council adopted an ordinance authorizing the City to enter into a "Tenth Amendment to District Cooling System Use Agreement" (the "Tenth Amendment"); and
WHEREAS, the Tenth Amendment is dated as of October 1, 1997;
WHEREAS, on the 5th day of February, 1998, the City Council adopted an ordinance authorizing the City to enter into an "Eleventh Amendment to District Cooling System Use Agreement" (the "Eleventh Amendment"); and
WHEREAS, the Eleventh Amendment is dated as of March 12, 1998; and
WHEREAS, on the 29th day of April, 1998, the City Council adopted an ordinance authorizing the City to enter into a "Twelfth Amendment to District Cooling System Use Agreement" (the "Twelfth Amendment"); and
WHEREAS, the Twelfth Amendment is dated as of June 1,1998; and
WHEREAS, on the 7th day of October, 1998, the City Council adopted an ordinance authorizing the City to enter into a "Thirteenth Amendment to District Cooling System Use Agreement" (the "Thirteenth Amendment"); and
WHEREAS, the Thirteenth Amendment is dated as of October 8, 1998; and
WHEREAS, on the 21st day of April, 1999, the City Council adopted an ordinance authorizing the City to enter into a "Fourteenth Amendment to District Cooling System Use
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Agreement" (the "Fourteenth Amendment"); and
WHEREAS, the Fourteenth Amendment is dated as of April 21,1999; and
WHEREAS, on the 16th day of February, 2000, the City Council adopted an ordinance authorizing the City to enter into a "Fifteenth Amendment to District Cooling System Use Agreement" (the "Fifteenth Amendment"); and"
WHEREAS, the Fifteenth Amendment is dated as of March 15, 2000; and
WHEREAS, on the 16th day of February, 2000, the City Council adopted an ordinance authorizing the City to enter into a "Sixteenth Amendment to District Cooling System Use Agreement" (the "Sixteenth Amendment"); and
WHEREAS, the Sixteenth Amendment is dated as of March 15, 2000; and
WHEREAS, on the 17th day of May, 2000, the City Council adopted an ordinance authorizing the City to enter into a "Seventeenth Amendment to District Cooling System Use Agreement" (the "Seventeenth Amendment"); and
WHEREAS, the Seventeenth Amendment is dated as June 1, 2000; and
WHEREAS, on the 27th day of September, 2000, the City Council adopted an ordinance .authorizing the change of control and name change from Unicom Thermal Technologies, Inc. to Exelon Thermal Technologies, Inc.; and
WHEREAS, on the 7th day of March, 2001, the City Council adopted an ordinance authorizing the City to enter into an "Eighteenth Amendment to District Cooling System Use Agreement" (the "Eighteenth Amendment"); and
WHEREAS, the Eighteenth Amendment is dated as of August 1, 2001; and
WHEREAS, on the 31st day of October, 2001, the City Council adopted an ordinance authorizing the City to enter into a "Nineteenth Amendment to District Cooling System Use Agreement" (the "Nineteenth Amendment"); and
WHEREAS, the Nineteenth Amendment is dated as of November 1, 2001; and
WHEREAS, on the 29th day of May, 2002, the City Council adopted an ordinance authorizing the City to enter into a "Twentieth Amendment to District Cooling System Use Agreement" (the "Twentieth Amendment"); and
WHEREAS, the Twentieth Amendment is dated as of June 1, 2002; and
WHEREAS, on the 23rd of June, 2004, the City of Chicago adopted an ordinance authorizing the City to enter into a "Twenty-First Amendment to the District Cooling System Use Agreement" (the "Twenty-First Amendment") which authorized the change of ownership and control of Thermal Chicago Corporation from Exelon Thermal Holdings, Inc. to Macquarie
3
District Energy, Inc.; and
WHEREAS, the Twenty-First Amendment is dated as of June 30, 2004; and
WHEREAS, on the 23rd day of June, 2004, the City Council adopted an ordinance authorizing the City to enter into a "Twenty-Second Amendment to the District Cooling System Use Agreement" (the "Twenty-Second Amendment") which authorized the change of ownership and control of Exelon Thermal Technologies, Inc. from Macquaire Investment Holdings, Inc. to Macquarie Infrastructure Assets, Inc. and collectively with the Original Agreement and all prior amendments described above the "Current Agreement" and the Current Distribution Facilities are described in Exhibit 1 and Exhibit 2; and
WHEREAS, the Twenty-Second Amendment is dated as of December 23, 2004; and
WHEREAS, on the 6th day of October, 2005, the City Council adopted an ordinance authorizing the City to enter into a "Twenty-Third Amendment to the District Cooling System Use Agreement" (the "Twenty-Third Amendment") which authorized amendments to the current Exhibits to include in the current Distribution Facilities a portion of East Randolph Street from North Columbus Drive to a point approximately 340 feet east of the right-of-way line of North Columbus Drive, and collectively with the Original Agreement and all prior amendments described above, the "Current Agreement" and the Current Distribution Facilities are described in Exhibit 1 and Exhibit 2; and
WHEREAS, the Twenty-Third Amendment is dated as of November 1, 2005; and
WHEREAS, on the 1st day of November, 2006 the City Council adopted an ordinance authorizing the City to enter into a "Twenty-Fourth Amendment to the District Cooling System Use Agreement" (the "Twenty-Fourth Amendment") which authorized amendments to the current Exhibits to include in the current Distribution Facilities with respect to Plant #1 Wabash Avenue from Adams Street to 200 feet north of Monroe Street, with respect to Plant #3 in the LaSalle Street Trolley Tunnel, from Lake Street to Kinzie, in Kinzie Street from the LaSalle Street Trolley Tunnel to 75 feet east of State Street and in Erie Street from State Street to Michigan Avenue and collectively with the Original Agreement and all prior amendments described above, the 'Current Agreement" and the Current Distribution Facilities are described in Exhibit 1 and Exhibit 2; and
WHEREAS, the Twenty-Fourth Amendment is dated as of November 1, 2006; and
WHEREAS, on the 30th day of July, 2008, the City Council adopted an ordinance authorizing the City to enter into a "Twenty-Fifth Amendment to the District Cooling System Use Agreement" (the "Twenty-Fifth Amendment") which authorized the extension of the Termination Date of the Original Agreement to December 31, 2040 in consideration of an increase in the use fee from 3.0% of Grantee's Total Gross Billings to 3.5% of Grantee's Gross Billings commencing on January 1, 2009 and another .5% increase of Grantee's Gross Billings effective January 1, 2014, and the City reserved the right after considering and analyzing business and economic realities to increase the General Compensation by no more than 2% of Grantee's Gross Billings in 2024 in any event not to exceed in the aggregate 6.0% of Grantee's Gross Billings throughout the term of the Current Agreement; and
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WHEREAS, the Twenty-Fifth Amendment is dated as of October 1, 2008; and
WHEREAS, the Grantee wishes to amend the current Exhibits to include in the Current Distribution Facilities a portion of Wabash Avenue from Erie Street to Superior Street, and a portion of Superior Street from Wabash Avenue to a point 100 feet west of Wabash Avenue, and collectively with the Original Agreement and all prior amendments described above, the "Current Agreement" and the Current Distribution Facilities are described in Exhibit 1 and Exhibit 2.
NOW, THEREFORE, BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1: The above recitals are expressly incorporated herein and made a part of this ordinance by reference as though fully set forth herein.
SECTION 2: Subject to the approval of the Corporation Counsel, as to form and legality the Commissioner of the Department of the Environment, the Commissioner of the Department of Transportation, and the Executive Director of the Department of Business and Licensing Affairs (collectively, the "Commissioners") are'hereby authorized to enter into and execute on behalf of the City, a Twenty-Sixth Amendment to the District Cooling System Use Agreement (the "Twenty-Sixth Amendment") substantially in the form attached hereto as Exhibit A, subject to such changes as shall be approved by the officials executing the same, their execution constituting conclusive evidence of their approval and this City Council's approval of any such changes or revisions therein from the form of the Twenty-Sixth Amendment attached hereto (including, but not limited to reduction or elimination of specific routes or locations herein authorized in the interest of public safety or in the public interest); provided, however, that no such change or revision may reduce General Compensation paid to the City contrary to the provisions of the Current Agreement as modified by the Twenty-Sixth Amendment attached hereto without further action of this City Council. Such officials may also negotiate in the Twenty-Sixth Amendment such additional environmental terms and conditions as shall be deemed desirable by the Commissioner of the City's Department of the Environment. In addition, such officials may also negotiate in the Twenty-Sixth Amendment such changes to the insurance terms and conditions set forth in Section 6 of the Current Agreement as shall be deemed desirable by the City's Risk Manager.
SECTION 3. All ordinances, resolutions and agreements, or parts thereof, in conflict with this ordinance are, to the extent of such conflict, hereby repealed.
SECTION 4. This Ordinance shall be in full force and effect upon its passage and approval.
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Exhibit A
6
This Twenty-Sixth Amendment to District Cooling System Use Agreement (the "Twenty-Sixth
Amendment"), dated as of_, 2011 (the "Effective Date") by and between the City of
Chicago, Illinois (the "City"), a home rule unit and municipality under Article VII of the Constitution of the State of Illinois, and MDE Thermal Technologies, Inc., an Illinois corporation (the "Grantee").
WITNESSETH:
WHEREAS, the City and the Grantee have entered into that certain District Cooling System Use Agreement dated as of October 1, 1994 (the "Original Agreement"), as heretofore amended (the "Current Agreement"), which grants to the Grantee (and its successors in interest) the non-exclusive right to use certain public ways of the City to construct, operate and maintain a district cooling system (the "System"); and
WHEREAS, Exhibit 1 to the Current Agreement describes the "Current Distribution Facilities" (as such term is defined in the Current Agreement) for the Grantee's System; and
WHEREAS, Exhibit 2 to the Current Agreement provides Jthe Location Map of the Grantee's System, including.the Current Distribution Facilities; and
WHEREAS, Grantee wishes to amend Exhibit 1 and Exhibit 2 to the Current Agreement (the "Current Exhibit") to include in the Current Distribution Facilities a portion of Wabash Avenue from Erie Street to Superior Street, and a portion of Superior Street from Wabash Avenue to a. point 100 feet west of Wabash Avenue as described and depicted in amended Exhibits 1 and 2, each as attached to this Twenty-Sixth Amendment (collectively, the "Amended Exhibits"); and
WHEREAS, the City Council of the City on_" 2011, adopted an ordinance
authorizing and approving execution of a Twenty-Sixth Amendment to the Current Agreement in substantially the form of this Twenty-Sixth Amendment, including the Amended Exhibits (the "Ordinance"); and
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WHEREAS, the City and the Grantee now desire to amend the Current Agreement, including the Current Exhibits, subject to the terms and conditions set forth below;
NOW, THEREFORE,
(-' -
It is agreed by the parties hereto as follows:
Section 1. The above recitals are expressly incorporated herein and made a part of this Twenty-Sixth Amendment by reference as though fully set forth herein. The capitalized terms not otherwise defined herein shall have the meanings set forth in the Current Agreement.
Section. 2. As of the Effective Date of this Twenty-Sixth Amendment, the current Exhibits are deemed superseded and replaced by the Amended Exhibits.
Section 3. The Grantee represents that, to the best of its knowledge, no member of the governing body of the City and no other official, officer, agent or employee of the City is employed by the. Grantee or.has a personal financial or economic interest directly or indirectly in this Twenty-Sixth Amendment or any contract or subcontract resulting therefrom or in the privileges to be granted hereunder except as may be permitted in writing by the Board of Ethics established pursuant to (Chapter 2-156) of the Municipal Code of Chicago (the "Code"). No payment, gratuity or offer of employment shall be made in connection with this Twenty-Sixth Amendment by or on behalf of any contractors to the Grantee or higher tier subcontractors or anyone associated therewith, as an inducement for the award of contracts, subcontracts or orders. Any agreement entered into, negotiated or performed in violation of any of the provisions of said Chapter 2-i 56 shall be voidable as to the City.
Section 4. Neither the Grantee nor its contractors shall be in violation of the provisions of Section 2-92-320, Chapter. 2-92 of the Code. In connection herewith, the Grantee has executed the applicable Certification required under the Illinois Criminal Code, 720 ILCS 5/33-11 (1994 State Bar Edition) and under the Illinois Municipal Code, 65 ILCS 5/1-1 et seq. (1994 State Bar Edition).
Section 5. It shall be the duty of the Grantee, all contractors, all consultants, and all officers, directors, agents, partners, and employees of the Grantee to cooperate with, the
Inspector General and/or Legislative Inspector General in any investigation or hearing undertaken pursuant to Chapter 2-55 and/or 2-56 of the Code. The Grantee shall inform all its contractors of the provision and require understanding and compliance herewith.
Section 6. The Grantee has provided copies of its latest articles of incorporation and bylaws and its certification of good standing from the Office of the Secretary of State of Illinois. The Grantee has provided the City with the Disclosure of Ownership Interest Affidavit for the Grantee and its direct and indirect corporate parents.
Section 7. If the Grantee conducts any business operations in Northern Ireland, it is hereby required that the Grantee make all reasonable and good faith efforts to conduct any such business operations in Northern Ireland in accordance with the MacBride Principles for Northern Ireland as defined in Illinois Public Act 85-1390 (1988 III. Laws 3220).
Section 8. Pursuant to Section 2-156-030(b) of the Municipal Code of the City of Chicago, it is illegal for any elected official of the city, or any person acting at the direction of such official, to contact, either orally or in writing, any other city official or employee with respect to any matter involving any person with whom the elected official has a business relationship, or to participate in any discussion in any city council committee hearing or in any city council meeting or to vote in any discussion in any city council meeting hearing or in any city council meeting or to vote on any matter involving the person with whom an elected official has a business relationship. Violation of Section 2-156-030(b) by any elected official with respect to this Twenty-Sixth Amendment shall be grounds for termination of the Current Agreement and this Twenty-Sixth Amendment. The term business relationship is defined as set forth in Section 2-156-080 of the Code.
Section 2-156-080 defines a "business relationship" as any contractual or other private ' business dealing of an official, or his or her spouse, or of any entity in which an official or his or her spouse has a financial interest, with a person or entity which entitles an official to compensation or payment in the amount of $2,500 or more in a calendar year; provided, however, a financial interest shall not include: (i) any ownership through purchase at fair market value or inheritance of less than one percent of the share of a corporation, or any corporate
subsidiary, parent of affiliate thereof, regardless of the value df or dividends of such shares, if such shares are registered on a securities exchange pursuant to the Securities Exchange Act of 1934, as amended; (ii) the authorized compensation paid to an official or employee for his or employment; (iii) any economic benefit provided equally to all residents of the city; (iv) a time or demand deposit in a financial institution;- or (v) an endowment or insurance policy or annuity contract purchased from an insurance company. A "contractual or other private business dealing" shall not include any employment relationship of an official's spouse with an entity when such spouse has no discretion concerning or input relating to the relationship between that entity and the City.
Section 9. Except as expressly modified in this Twenty-Sixth Amendment, all other terms covenants and conditions in the Current Agreement (including exhibits and attachments) remain unchanged and all affidavits, certificates and representations in the Current Agreement (including exhibits and attachments) are deemed reaffirmed as if made as of the date hereof.
IN WITNESS WHEREOF, the City has caused this Twenty-Sixth Amendment to be duly executed in its name and behalf as of the date first written by its Commissioner of the Department of Environment, its Comptroller and ; its Commissioner of the Department of Transportation and the Grantee has signed and sealed the same on or as of the day and year first written.
(SEAL)
CITY OF CHICAGO
City Clerk
By.
Title: Commissioner of the
Department of Environment
By:
Title: Comptroller
By:
Title: Commissioner of the
Department of Transportation
Reviewed as to form and legality:
Assistant Corporation Counsel or Senior Counsel
ATTEST: MDE THERMAL TECHNOLOGIES, INC.
_ By:
Title: President
DISTRICT ENERGY
John Hancock Life Insurance , Company (U.S.A.)
49199%
Senior Debt USS150M
* Forrnerty Macquaria District Energy,
Macquarie Infrastaacture Comp any LLC
Macquarie In&astructure Company hjc.
Macquarie D&tnct i nergy Holding:. Ill IK
50.01%
Macquarie District Energy HoldingsII LLC
100%
Macquarie District Energy-Holdings LLC
100%
Macquarie
j, District Energy LLC *
100%
Thermal Chicago Corporation
Lender
US$25MNote At 12.5%
Borrower
100%
ETT Nevada, Inc.
75%
Senior Debt US$19n>
Nonhwind AKiJilin I LC
North wind Cm-diO LI l
1 100%
EFT National, Power, Inc.
100%
Nonhwind M dwjv, LI (.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I ~ GENERAL1 INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Check ONE ot the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: L $y the Applicant ^OR
2. [ ] a legal entity holding a direct br indirect interest in the Applicant State the legal name of the Applicant in which the Disclosing Party holds an interest_______________
OR
3. [ ] a legal entity with a right of control (see SectioniLB.l .) State the legal name of the entity in which the Disclosing Party holds a right of control: ., .........v*.,,,,,;........_,.
B, Business address of the Disclositig Party: J0$ 0. ^££$0*/ £i- V/S. ^/-B>/^_ _
C. telephone: 3JA\W1'/tzM Fax: W7>03/L ^±j{M,pa^nU^^t^2.
D. Name of contact person^ J
E. Federal Empldyer Idehiificatidri No. (if you have one))
F. Brief descriptidn of cdntfact, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and locationof property^ if applicable)■:
G. Which City agency or department is requesting this EDS? h&££ /dsAfiT*
if the Matter is a contract being handled by the City's Department of ProcurementServices, please complete the following:
Specification # ., . , . . , .,, . ... ... and Contrad # -. .._-.,
Ver. o^i-io
I
Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP^ INTERESTS
A. NATURE OP THE DISCLOSING PARTY
1. Indicate the nature of tfae Disclosing Party;
[ ] Person [ ] Limited liability company
t] Publicly registered business corporation [] Limited liability partnership
J^" Privately held business corporation [ ] Joint venture
[] Sole proprietorship [ j Not-for-profit corporation
[ ] General partnership ' (Is the not-for-profit corporation also a 501(c)(3))?;
[ j Limited partnership []Yes [JNo
[ ) Trust [ ] Other (please specify)
2. For legal entities, the state (of foreign country) of incorporation or organization* if applicable: jLL/AfdjS _...
3. For legal entities not organized in the State of Illinois: Has the organizationregistered to do business in the State of Illinois asa foreign entity?
[JYes [JNo jj'N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names arid titles of all executive officers arid all directors of the entity. NOTE*. For not-for-profit corporations, also: list below all meriibers, if any, which are legal eritities.-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 partnef shipi lirriited partriership, limited liability company, limited liability partnership or joint venture, list below the name arid title of each general partner, managing member, manager or any other person or entity that controls the day46-day management of the Disclosing Party. N<OTE: Each legal entity listed below must submit an EDS on Its own behalf.
% Ptease'proVide\i0ie'folidwm|;'UToM8tido concerning each person or entity having a direct or indirect beneficial interest (mcluding 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 1 of 13
-interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other sirhilar 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 IttU^^clb'rai^.
Name Business Address Percentage-Interest in the
Disclosing Party
/t~. CeOkDL__....
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?
t j Yes j^No
If yes, please identify below the name(s) of such City elected official(s) afld describe such relationship(s):
SECTION IVDISCLOSURE 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 #ho 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 wftose 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 Pai^-iiatt'st either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disciosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "tb.d." is
>> ft not an acceptable respbniei
(Add sheets if necessary)
[ ] Check here ifthe Disclbsing[Patty has not retained, nor expects tofetain,; any such persons orentities. '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: [ 1 NO i)f No person directly of indirectly owns i 0% or more of the ,
Disciosing Party. ,
If "Yes," has the person entered into a; rc6uft-approv&d agreementfof payment of ail support owed and is the person in compliance with that agreement?
t ] 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 me Disciosing Party submitting this EDS is the Applicant and il doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling persbh is curt#htly indicted or charged with, of has admitted guilt of, of has eVer been convicted of, of placed under Supervision for, any criminal rifiWse involving actual; attempted;, or conspiracy tocommit bribery, thefts ffStid, fbfgefy, 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
I
'2', T£d6»clp.sMg Party.-and, if me Disclosing Pa%4&a4ejgai e_fi% aif dfthose flefMnl-Sf* entities identified in Section II.B.i. of this EDS:
a. aire not presentlydebarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal^ state of local unit of government;
b. 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 cdntfact under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery;; bribery; falsification ordestruction of records; making, false statements; or receiving stolen property;
c. are hot presently indicted for, or criminally or civilly charged by* a governmental entity (federal, state of local) with committing any of me offenses set forth in clause B.2.b. of this Section V;
d. have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal* state or local) terminated fof cause or default; and .
e. have not, within a five-year period preceding, the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, orjn any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any stateVor any other unit of local government.
31. The certifications in subparts 3, 4 arid 5 concern:
. the Disclosing Party;______ . . ------ --------- -
ariy "Cohtfactor" (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 Entity1' (meaning a person or entity that, directly or indirectly: controls the Disclosing Party,-is controlled by the Disclosing Party, of 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 Cdntractofs, the term Affiliated Entity means a person or entity that directly or indirecily 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 dr any Affiliated Entity of any other official, agent or employee of the Disclosing Party, ariy 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 Disclbsing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years hfefofe 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 ih/cbhnectibn with the Matter:
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer of employee of the City, the State of Illinois, or any agency of the federal government or of any state or local gbverflineni hMfce Vrifted States of America, in that officer's or employee's official capacity;
b. agreed or colluded with other bidders or prospective bidders, of 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
c. made an admission of such Conduct described in a. or b. above that is a matterof record, but have, not been prosecuted for such conduct; or
d. ; violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance),
4. Neither the Disclosing Party, Affiliated Entity of Coritf actor, of any of their employees, officials* agents or partners, Is barfed from contracting with any unit of state or local government as a result of engaging in:or being convicted of (1) bid-rigging in viblation 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 dr of the United States of Amefica that contains the same elements as the offense of bid-rigging or Bid-fotating.
5 . Neither the Disclbsing Party nor any Affiliated Entity is listed on any of the following lists ^maintained by the Office of Foreign Assets Contfol 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 andthe Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (GovernmentaiEthics) of the Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
-JLJA_ - . . .....,
Page 6 of 13
If trie letters "NA," the wbrd;,,Noriei" of ho resporise^appears on the lines above, it will be conclusively presumed that the DisclosingParty^ certified to the above stated
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1V The Disclosing Party certifies that the Disclosing Party (check one)
C 3 is ^ is not
a "financial institution" as defined ih Section 2-32-455(b) of the Municipal Cod&
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and wili not become a pfedatofy lender as defined in Chapter 2-32 of the Municipal Code; We further pledge that none of ouf affiliates island 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 lende r 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 2-32-45 5(b) of the Municipal Code); is a predatory lender within the meaningof Chapter 2-32 of the Municipal Code, explain here (attach addifidhal pages if necessary):
If the letters "NA," the word "None," or ho 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.
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 per son or entity in the Matter?
□ Yes, ^No
NOTE: If you checked "Yes" to Item D. 1., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Page 7 of 13
2. ytilessisold pursuant to a process of competitive bidding, or Otherwise permittedj no City elected official of empldyee shall have a finahcial interest in his or her own name: or in the name of -any dther pefsbh or entity in thelpufchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessmentsj 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?
t ] Ves [ ] No
3. 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 of employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. of 2. below. If the Disclosing Party checks 1., the Disclosing Party.must disclose;below or in an attaehjtneiit to this EDS. all information requiredby paragraph 2., Failure to comply with these disclosure fequirements may make any contract entered into with the City in connection with the Matter voidable By the City.
y(. 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 slavefy of slaveholder insurance policies during the slavery era (including insurance policies -issued to slaveholders that provided covefage 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 of 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:
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SECTION VI- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS'
NOTE: If^ the Matter is federally funded, complete this Section VI. Ifthe Matter is riot federally funded* proceed to Section VIL Fbr purposes of this Section VI, 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 fhade 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 ifthe word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered underthe 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 hot 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 ofto pay-any person or entity to influence or attenipt to influence ah officer or employee of any agency, as defiried 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, "ainendi or modify any federally funded contract, grant, loan, or cooperative agreement.
3. the Disciosing Party will submit ah 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;
4. 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 arid will not engage ih "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain Certifications equal in form and substance to paragraphs A. l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain alt such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
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B'. CERTIFICATION REGARDING E0DAL EMPLOYMENT GPPdRTlJNlTY
If the M£ttet4s:'%'Mlly^ded«: federal regulations require the Applicant and all proposed subcontractors to 8tt6Mi^itkeYdlldw:ifl'g information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the.Applicant?
t ] Yes [ J No
If "Yes," ariswer the three questions below:
1. Have you developed and db you have oh file affirmative action pfogranis pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[JYes []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?
[]Yes []No
3. 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:
SECTION VIi; =- ACKNOWLEDGMENTS, CONTRACT' INCOKPottMlON, COMPLlANeE,PENALTIES.;:DISCLOSURE
The Disclosing Party understands add agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement* City assistance, or other City action, and are material inducements to the City's execution of any contract of taking other action With respect to the Mattef. The Disclosing Party understands that it must comply with all statutes* ordinances, and regulations on which this EDS is based.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 arid 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, of transactions. The full text of these ordinances and a training program is available on line at www.citVofchicago.org/Ethics. arid may also be obtained from the City's Board of Ethics, 740 N.
Page 10 of 13
Sedgwick St., Suite 500, Chicago, IL 60610^(3^2) 744-9*560. the Disclosing Party must comply fully withThe applicableofdiharices.
C. Ifthe City detefmmes 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 thei contract of agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or decliningto 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.
D. It is the City's policy to make this document available to the publie on its Internet site and/or upon request. Some or ail of the, information provided On this EDS arid any attachments to this EDS rtiay 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 EDS1, the Disclosing Party waives and releases any possible fights or claims which It may' have against the City in connecfioh witn the public release of information -contained in this EDS arid also authorizes the City to vefify the accuracy of any information submitted iri 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. Ifthe Matter is a coiirract being handled by the City's Depaffrherit of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTEs With respect to Matters subject to Article I of Chapter 1-23 of theMunicipal Code (impdsirig^PERMANEHT INELIGIBILITY for certain specified offerises), 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:
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 riot limited to, all watef 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 Disclosirig Party is the Applicant,; the Disclosing Party will obtain from ariy 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.
Page 11 of 13
NOTE: Ifthe Disclosing Party cannot certify as to ariy ofsthe items in F^L,F.2. or P.3. above, an explatiatory statement must be attached!tofhis 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) ort behalf of the Disclosing Party, and (2) warrants that ail certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurati and complete as of the date furnished to the City.
(Print or type name of Disclosing Party)
(Print or type name of person sigriing)
(Print or type title of person signing)
Signed and sworn to before me on (date) "7//'t/'///
Notary Public.
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT A^-AFEtDAYlT
APPENDIX A
FAMttlAL MLATlONSfflPS W
Tills Appendix is to be completed only by (a) tbe Applicant, and (lb) any legal entity which has a direct ownership interest in the Applicant exceeding 13 percent 141s 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 Disclbsmg P^ty 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 of stepmother, stepson or stepdaughter, stepbrother or st^sistef of hi^-bi^ef''ot'-Mlf-steter.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Sectidn ILB.l .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disciosing Party is a general parthefship; all general partners and limited partners of the Disclosing Party, ifthe Discldsirig Party is a limited partnership; all managers, managing members and members of the Disclosing Party, ifthe Disclosing Party isa lirttited liability company; (2) all principal officers of the Disclosing Party; arid (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 aiegal entity or any person exercising similar authority.,
Does the Disclosing Party or any "Applicable Party" of any Spouse or DdrheStic Partner thereof currently have a "familial relationship" with an elected city official or department head?
N.Yes $]No
If yeSj please identify below (1) the name and title of such person, (2)!the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
2
err v op chicaoo
ECONOMIC PiSCLOS-i^^
AND MW&M;if
SECTldrff^ GENERAL- INFORMATION Ai *-eg«l name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Chiclt ONE of the following three boxes:
Indicate Whether the Disclosing Party submitting; this EDS is* i* t ] the Applicant OR
a legal entity holding a direct or indirect interest ih theAppiicant, State the legal nameof the
Applicant in which the Disclosing Party holds an interest: ^g^A^^.^&^><^&J^ OR ~* .~.t*r"~~f» >^
3- t] a legal entity with a right of control (seeiSecti6ttII,BVl;J State the legal name of the entity in which the Disclosing Party holds a right of control:..
B. Business address of the Disclosing Party: c^OO tf . S^£maAl £jLir-&. ■
C Telephone: 3/3 ■ W l /^> 66 Fax: 3fZ*-mi3r &m&> Email:J-j^l.yOagn&$sttj@
t>. Name of contact person: T^flW^^
E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or bmeruhdertaking (referred to below as the '♦Matter1') to wMch this EDS pertains. (Include project number and location of property, if applicable);
G. Which city agency or department is requesting this BPS? J(llS<!>7~_-,
If the Matter is a contract being handled by the City's Department of Procurement Services,, please complete the following:
Specification #
and Contract #
Ver. 0941-10
Page 1 of 13
1
SECTION H - DiSCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSlNGvPARTY
1, Indicate the naturedf the Disclosing Party:
[ ] Person
t ] Publicly registered business corporation
Privately held business corporation
| ] Sole proprietorship
[ ] General partnership
[] Limited partnership
[ ] Trust
[ ] Limited liability company
[ ] Limited liability partnership
t ] Joint venture
[ j Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
tjYes []No [ 1 Other (please specify)
2. For legal entiiies^the state (or foreign country) of incorporation or organization, if applicable:
3. For legal entities not organized ih the State of Illinois: Has the organization registered to do business in the State Of Illinois as a foreign entity?
'Yes [TNo []N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full/names and titles of all executive officers andiall directors of the entity. NOTE: For not-for-profit corporations, also list below ail members, if any, which are legal entities If. there are no such"members, write ''hd members;'* For trusts* estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liabilitycompany, limited[ liability partnership or joint vehturej list below the name and title of each general partner, managing, member, manager or any other pefsbh brentity that controls the day-to-day mahagemeiit of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Title
4km er* /Mm
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 f Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
inlefestof a member or manager in a limited liability company, or interestof'a beneficiary of a trust, estate orother 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?
[1 Yes j^No
If yes, please identify below the name(s) of such City elected official(s) and describe such retationship(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 of 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 no^fof-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 Disclbsing 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
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 tx^0 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 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 bjtoioak'grPatty''atid^if-ffie Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B\ 1. of this EDS:
a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded fronrahy transactions by any federal, state or lbeal unitof government;
b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudgedguilty * 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;
c. 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;
d. 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; arid
e. 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 certificatibhs iri subparts 3,4 and 5 concern:
the Disclosing Party;
. any "Contractor" (meariirig ariy Contractor or subcontractor used by the disclosing Party in connection with the Matter; including but riot 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 Disciosing 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 iridirectjy 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 br 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 Diaciosing Pafty or any Contractor nor any Agents have, during the five:years before the date this EDS is signed, of, with reispect to a Cphtfactor, 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 of engagement in connection with the Matter:
a. bribed or attempted to bfibe, 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 of local government in the United States of America* in that officer's of employee's official capacity;
b. agreed of colluded with other bidders or prospective bidders, of been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders of prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
'&S made an admission of such conduct describedin a. or b; above that is a matter of record, but have not been prosecuted for such conduct; or
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with ariy unit of state or local government as a result Of engaging in or being convicted of (I) bid-riggingfitt violation Of 720 ILCS 5/33E-3; (2) bid-rotating4n violation of 720 ILCS 5/3 3 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-fotating.
%■ Neither the Disciosing 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 Conifherce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
6. The Disciosing Party understands and shall comply with the applicable requirements Of Chapters 2-55 (Legislative inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below: !
jjfA . _._-. . .......■_-___-
Page 6 of 13
Ifthe letters "NA," the word "None," or rid response appears on the lines above, it will be fionelusiveiy presumed that the Disclosing Party certified to the above statements.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
I... The Disclosing Party certifies that the Disclosing Party (check one)
[lis ^ is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. if the Disclosing Party IJJ a financial institution, then the Disclosing Party pledges:
"We are not and will hot 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 of 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):
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 % Chapter 2-15 6 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 entity in the Matter?
[JYes ^No
NOTE: If you checked "Yes" to Item D.l,, proceed to Items D.2. and D.3. If ybu checked "No" to Item D.l,, proceed to Part E.
Page 7 of 13
2. 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 of assessriiehts, or (ill) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensationrfor property taken pursuant to the City's eminent domain power does not constitute- a financial interest within the meaning of this Part b.
Does the Matter involve a City Property Sale?
[JYes [JNo
3. it you checked "Yes" to Item D.l., provide the names and business addresses Of me City officials or employees having such interest and identify the nature of sueh interest;
Name Business Address Nature of Interest
4. The Disciosing Party further certifies that no prohibited financial interest in the Matter will be acquired by ariy City official or employee.
£. 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------
comply with these disclosure requirements may make any cohtfact 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 ali predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided Covefage for damage to or injury or death of their slaves), arid the Disclosing, Party has found rio 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 verifiesthat the following constitutes full disclosure of all such records, including the names of any arid ail slaves or slaveholders described in those records:
\
Page 8 of 13
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED. MATTERS:
NOTE: If the Matter Is federally funded, complete this Section VI. If the Matter 1§ not federally funded, proceed to Section VII. For purposes of this Section VL 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 of 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):
(iittd'-ex^tafla^p#a^peaf>of begins on the lines above, or if the letters "N A" or if the wdrd-,,Nbne!' appear, it will be conclusively presumed that the Disclosing Party means that NO persons of entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.) J
2. The Disclosing Party has not spent and will not expend any fedef ally 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 dr entity to influen ce 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, of an ernpidyee-of a member of Congress, in c dnnection with: the award of any federally funded contract, making ariy 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. .......
3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A. 1. and A.2. above.
4. 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; of (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.L through A.4. above ffom 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.
Page9of 13
B, CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is fedef ally funded* federal regulations require the Applicant and all proposed subcontractors to submit the following info or in Writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes []No 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.)
[]Yes []N6
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs* of the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
t]Yes (INo
3. Have you participated in any previous contracts or subcontracts subject to the equai opportunity clause?
[JYes []Nd
If you checked "No" to question I. or 2. above, please provide an explanation:
SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLI ANCE, PENALTIES, DISCLOSURE
The Disciosing Party understands and agrees that:
A. the certifications, disclosures, and ackriowledgments contained in this EDS will become part of any contract or other agreement between the Applicahfahd the City in connection with the Matter j whether procurement, City assistance, of other City action^ and are material inducements to the; City'se^ of any contract or takthig.^ilfer 'M^oiii with respect to ithe 'Matter.: The DisclosingParty undefstahas that it must comply with all statutes, ordinances, and regulations on which this EDS is based:,
EL the City's Governmental Ethics and Campaign Financing Ordinances* Chapters 2-156 and 2-164 of me Municipal Code, Impose certain duties and obligations on .persons, 'or ^tier^eikjng-City contracts, work, business* of transactions. The full text of these ordinances and a training program is available on line at www.citvofchkaed;org/Ethics. and mav also be obtained from the City's Board of Ethics, 740JNV
Page 10)of 13
Sedgwick SL, Suite 5O0^ehtC.ago, IL 60610, (312) 744-9660. the Disclosing Party must comply fully with me applicable ordihances;
C. If the City determines that any infdnnatidn prdvided in this EDS is false, incomplete or inaccu rate, any '^rijtns^of'p^r'-a^emefli in connection with Which it is submitted may be rescinded of be void or voidable, arid tht City rnay pursue any remedies under the cohtf act of agf eefnent (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/dr declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact rriay include incarceration and an award to the City of treble damages.
D. It is the City's policy to make this document available to the public dri its Internet site and/of upon request, Sdfrie of 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 cotripleting andI sighing this EDS; the Disclosing Party waives arid releases any possible rights or claims which it may have against the City ih connection with the public release of information confined iiii#i8 J^S'anKtalsd authorizes the City to'verify:^ac;£ura^y b?any information submitted in this EDS.
E. The irifbrmatiori 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 PfocurernentJServices, the Disciosing Party must update this EDS as the Contract requires. NOTE i With fespect tb 'Matters subject to Article I of Chapter 1-23 of me Municipal Code (imposing PERMANENT iNELIGIBILiTY for certain specified offenses), the information provided herein regarding eligibility riiust be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclbsing Party represents and warrants that:
F. l. The Disclosing Party is riot 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 hot limited to, all water charges, sewer charges, license fees,;parklng tickets, property taxes or sales taxes.
PJ If the bisfclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not Use, nor permit their subcontfacfbfs to use, any facility listed by thei 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 Disclbsing Party will obtain fforri any coritractbrs/8ubebntractors hired or to be hired irivcbriri'ectiori-'^ilb theMattef certificatipns equal in form arid 4u^$ia^ce^tb.#o'$e.M.1 .-and F.2. above and will nbt, withbut the pfidf written consent of the City, use any such coritraetbr/subcbritractor that does not provide such certifications of that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
Page 1 Lof 13
If the Disclosing Party cannot certify as to any bftheltems in F.L, F.2. or F.3. above, an explanatory statement^musf^e atfi^hed to this EDS;
CERTIFICATION
Under penalty of perjury, the person signing below. (1) warrants that he/ihe is auwonied to execute this EDS and Appendix,A5(ifapplicable) ohbehalfof the;Disclosing Party, and (2) warrants that all certifications and statements contained ih this EDS and Appendix A (if applicable) are true, accurate actd complete as of the date furnished to the City.
(Print or type name of Disclosing Party)
(Sign here)
(Print or type name of person signing)
(Print or type title of person signing)
Signed and sworn to before me on ^date)
at (LtifeL County. JL- (state). <
Notary Public.
Commission expires:.
Official Seel Maureen ft Prurity Notary #uttlte;Ste» of Illinois WiyiComMiaslon Expires OS/03/2014
Page 12 of 13
ClTYOECllCAGO ECONOMICDISCLOSURE^SMtEM^NT A^D AFWAVJT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OmCIALS AND DEPARTMENT HEADS
This Appendix is tb be completed only by (a) the Applicant, and (b) any legal entity which has a dlreei ownership interest in the Applicant exeeeo^ 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 Disclbsing Party must disclbse whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner ther^eof currently has a "familial relationship" with any elected city official or department head. A "familial relatidnship" exists if, as of the date this FJDS is signed, the Disclosing Party Of any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or ariy 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, famef4n-law, mbthef-iri^law, son-in-law, daughter-in-law, stepfather of stepmother, stepson of stepdaughter, stepbrother or stepsister of half-brother of half-sister.
"Applicable Party" means (i) all executive officers of the DiscibskgParty listed in Section IfcB. l .a. , if the Disclosing Party is a corporation;-all partners of the Disclosing Party, if the DiscIosmgParty is a general partnership; all general parmers.and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclbsing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; arid (3) any person having more than
a 7.5 percent ownership interest ih the Disclosing Party. "Principal officers" means the president; chief____________
operating officer, executive director, chief firi^ any person
exercising similar authority. .
Does the Disclosing Party or any "Applicable Party" or any Spouse of Domestic Partner^ mefebf currently have a "familial relationship" withan elected city'officialor department head?
if yes, please identify below (1) the hanieand title of such person, (2) the name of the legal entity to which such person ia connected; (3) the name; arid title of the elected city official br department head tb whom such pefson has a familial relationship, and (4) the precise nature of su^
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A, Legalname 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: U [] the Applicant Oft
2. fV 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: fflbtf'■ftfg&/>y}M^ 'M&JfMdW&teS>J//f&
OR
3. [ 1 a legal entity with a right of control (see Section II.B.l,) State the legal name of the entity in which the Disclosing Party holds a right of control: _ ... _ .
B. Business address of the Disclosing Party: <$6d ft). BluL. *$l£>W
C. Telephone: 2/A■ ¥¥%/6odO Fax: g/£ &V7-dg/fe Email:J\m. f>a^ v£><^(@
.... a ji)efwdl(z>hi£tiqo,£&rn
D. Name of contact person: rrt6>AtU£/4?' <->
E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred tb below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
O. 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 #_ . . .
V«r. 09.01-10
Page I of 13
SECTION; II«- DISCLOSURE OF OWNERSHIP iNfERESTS A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person
1] Publicly registered business corpdratioh [ ] Privately held business corporation [ ], Sbie proprietorship I ] General partnership [ j Limited partnership [] Trust
pi Limited liability company t ] Limited liability partnership t ] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?
[]Yes []No t ] 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 ali directors of the entity. NOTEi 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 tfu8t8, estates or other similar entities, list below the legal titleho}der(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 Disclbsing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name .
mm A
/5 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 liabilitycompany, or interest of a beneficiary of a trust, estate of^ther- similar entity. 'If none, 8Me,<4Ndne^''BjOTfe Pursuantio Section 2-154-030 of the Municipal Gode of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended tb achieve full disclosure.
Name Business Address Percentage Interest in the
. Disclosing Party
SECTION IHBUSINESS RELAtlONSHlPS WIf CITY ELECTED OFFICIALS.
Has the Disclosing Party had a "business relationship," as defined irt Chapter 2-156 of the Municipal Code, With any City elected official in the 12 months before the; date this EDS is signed?
flYes
If yes, please identify below the hame(s) of such City elected officials) and describe such feiatiottshipts):
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER REGAINED 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 Mattef, as well as the nature of the relationship, and the total amount of the fees paid or estimated tb be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclbsing 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-fbr-profif 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 tb influence arty 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 if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person 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?
[JYes [JNo j^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 ali support owed and______ -
is the person in compliance with that agreement?
[ ] Yes [ ] No
B. 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 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
2. the Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section liB.l. of this EDS:
a. - are not presently debarred, suspended, proposed for debarment, declared ineligible of voluntarily
excluded from any tf ahs^ctions by any federal, state or local unit of government;
b. 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 peffofmirig a public (federal, state or local) transaction or contract under a public transaction; a violation of federal dr state antitrust stattites; fraud; embezzlement; weft; forgery; bribery; falsification or destruction of records; making false statements; of receiving sfolen property;
c. are not presently iridieted 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,h; of this Section V;
d. have not, within a five-year period preceding the date of this EDS, had orie or more public transactions (fedefal, state or local) terminated for cause of default; and
e. have not, Within a frve-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 of by the federal government, any state, of any other unit of locargdvemment.
3. The certifications in,subparts 3, 4 and 5 concern:
the Disclosing Party;
any "Contractor" (meaning any contractor of 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 of 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 fedefal of state or local government, including the City, using substantially the same management, ownership, of principals as the ineligible entity); with respeet id 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 of entity;
any fesponsible 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 ihe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, nor any Gontract6r*.ttofvahy Affiliated Entity of either the Disclbsing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect'tb a Contractor, an AffiliatedI Entity, or an Affiliated Entity of a Cbntractof during the five years before the'date of such Contractor's or Affiliated Entity's contract or engagement in connection wi&the Matter:
a. 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 of employee's official capacity;
b. 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
c. 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
d. violated theprovisions of Municipal Code Section 2-92-6 LO (Living Wage Ordinance).
4, Neither the Disclbsing Party, Affiliated Entity of Contractor, or any of their employees, officials, agents Of partners, is barred from contracting with any unit of state of local government as a result of engaging in or being convicted of (l) 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 theUnited States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
5.- Neither the Disclosing Party nbf 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.
6. The Disciosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector-General) and 2-156 (Governmental Ethics) of the Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Page 6 of 13
Ifthe letters "NA," the word "None," orno response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that-the Disclosing Party (check one) [Jis ^(ishdt
a "financial institution" as defined ih Section 2-32-455(b) of the Municipal Code.
2, Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatdry lender as defined in Chapter 2>32 of the Municipal Code. We further pledge that none of our affiliates is, and hone 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 becorhing 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 ih Section 2-32-455(bj of the Municipal Code) is a predatory tender 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 Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-15 6 of the M unicipal Code have the same meanings when used in this Part D.
I. 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?
[JYes )4No
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.
Page 7 of 13
2. Unless sold ipufsuanl to a prbcess of competitive bidding, or Otherwise peftnltted, rid City elected official or employee shall have a financial interest in his or her own name or iri the name of ariy other person or entity iri the purchase of any property that (i) belongs to me City, or (ii) is sdld for iaxei bit ^e&fai^i or (iii) is solrfby virtue of legal process at the suit ofthe 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?
tlYes (]No
3. If ybu checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interests and identify the nature of sucfii interest:
Name Business Address Nature of Interest
4. The Disciosing 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 L of 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 -comply with these disclosure requirements may make- ariy contract entered into with ihe City in connection with the Matter voidable by the City.
X **' The Disclosing Party verifies that the Disciosing Party has searched any and all records of the Disclosing Party arid any and all predecessor entities regarding records of investments of profits fromyslavery 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 noi suchreebfds.
_2. The Disclosing Party verifies that, as a result of conducting the search iri step 1 above, the
Disclosing Party has found records of investments or profits from slavery of slaveholder insurance policies. The Disclosing Party Verifies that the following constitutes full disclosure of all such records, including the names of any and alislaves or slaveholders described in those reebfds:
Page 8 of 13
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NBf fi: If theMaiter Is federally funded, complete this Section VI, If the Matter Is hot federally funded, proceed to Section VII. For purposes of this Sectrort VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying Contacts oh 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 of 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. 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 Gongf ess, 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 arty cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant,, lpanvor cooperative agreement. _........_____
3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l . and A.l. above.
4. The Disclosing Party certifies that either: (i) it is hot 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 riot engaged arid will riot engage in "Lobbying Activities". ,
5. If the Disclosing Party is the Applicant,: the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disciosing 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.
r
Page 9 of 13
B. CERTlPlCAfION REGARDING EQUAL EMPLOYMENT OPPORTUNiW
If the Matter is feS^iy-fostiieAt-iieAetal regulations require the Applicantand allproposeds
subcontractors to'-submitMe-Ibilowiiig information with the
negotiations;
Is the Disclosing Party the Applicant?
NYes []No If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant id applicable federal regulations? (See 41 CFR Part 60-2.)
[JYes . []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?
UYes UNo
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[]Yes []No
If you checked "No" to question 1 i; or 2. above, please provide an explanation:
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORAf ION,. COMPLIANCE,PENALTIE'S^MSCLOSUKEv
The Disclosing Party understands and agrees that;
A. The certifications, disclosures, and acknowledgments contained in this EDS Will become part of any contract Or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and 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.
B. 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.
Page 10 of 13
S«d'gwlek<Slv-Saile'-50G; Chicago^ IL 60610, (312), 744-9fe60. the Disclosing Patty must comply fully with the applicable ordinances.
C; Ifthe Citydetermines that any information provided in this EDS is false, incomplete or inaccurate, any contract of other agreement ih connection with which it is Submitted may be rescinded of be Void of Voidable, and the City may pursue a under the contract or agreement (if not rescinded or
void), at law, or in equity, including terminating the Disclosing Party's participation itt the Matter and/or declining to allow the Disciosing Party to participate ih 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. ' -
D. 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, of otherwise. By.completing and signing this EDS, the Disclosirig Party waives and releases any possible rights or claims which it may have against the City ih 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; 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. NOTEi 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 mast-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 arid Warrants thai:
F. 1. The Disclosing Party is not delinquent in the payment of any fax administered by the Illinois Department;of Revenue, nor are the Disclosing Party of 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 contfactors/SUbcontfactors 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 ofthe City, use any such contractor/subcontractor that does not provide such Certifications or that the Disclosing Party has reason to believe has riot provided or cannot provide truthful Certifications.
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NOTE: If the Disclbsing Party can^t certify as to any of the items in .'P. 1FX or Fi . above, ah explahatorystatement must be attached to ttiisrEDSi/
CERTIFICATION
Under penalty of perjury; the person sighing below: tl) 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)
(Sign here)
(Print or type name of person signing) (Print or type title of person signing)
Signed and sworn to before me on (date)_'"?■//
a* &ddtC County, /£*
(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 HE ADS
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 2454-015, the Disclosing Party must disclose whethersuch Disclosing Party or any "Applicable Party*' or any Spouse dr Domestic Partner thereof currently has a/'famitial reiationship"iwith any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclbsing Party of any "Applicable Party" or any Spouse or Domestic Parmer thereof is related to the mayor, any alderman, the citycierk,;the .city treasurer or ahy city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother of 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 of half-bfbther or half-sister.
"Applicable Party" means (1) ail 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 paftnership; 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 m;the Disclosing Party. "Principal officers" means the president, chief . operating officer, executive director, effief financial o^ of 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 ah elected city official or department head?
NYes. |^No
If yes, please identify below (1) the name and title of such person, (2): the narrfe of the legal entity tb 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 ECONDMiC DISCLOSURE STATEMENT ANt> AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. 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:
1. [ ] the Applicant
OR
2. t^r| a legal entity Balding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an: interest: Mg' 1%&/£0ffl,^&&A/6M6/^jAiC«
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:_. ,. _■ .
B. Business address ofthe Disclosing Party: £60 .0- <fy(l£*Z>6tf Ml~V&. _
C. Telephone: -Mf* jfadd Fax: _%Q- ■ W'7- J2>/£ Email:J im.ffiqtf V^ad (p'
- - ■ ---------------"": ^erMal&h l td so. C&m
D. Name of contact person: ^I fD is»A/OS>/iT
E. Federal Employer Identification No. (if you have one)
F. Brief description of contract, transaction or other undertaking (referred tb below* as the "Matter") to which this EDS pertains. (Include project number and location Of property, if applicable);
O. 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 #_ ._ f_and Contract # _____________________
Ver. 09-01-10
Page l of 13
SECTION II DISCLOSURE OF OWNERSElP' lNTERE'St^
A; NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing5 Party:
[ ] Person
■{.] Publicly registered business cbfpbratioh
11 Privately held business corporation
[ ] Sole proprietorship
[ ] General partnership
{] Limited partnership
[) Trust
Limited liability company [ ] Limited liability partnership [ ] Joint venture {] Not-for-profit corporation (Is the hbt-for^profit corporation also a 501 (c)(3))?
13 Yes t }No
[ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation of organization, if applicable;
______
3. For legal entities riot organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
' 1<fYes []No [1N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1, List below trie full narries and: titles of all executive officers arid all directors of the entity. NOTEi For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such membefs,,write "ho members," For trusts, estates or Other similar entities, list below the legal titlehoider(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint; Venture, list below the name arid title of each general partner, managing member; manager or ariy other person or entity thatcontrols the day-to-day manageaient of the Disclbsing Patty, NOTE: Each legal entity listed below must submit an EDS on its own behalf,
N_m6' Title
34wa d £>v/hf_ggrp ^^&/6sAJr___
dymgZ /h#k£_ )>j£&csn>#l ____,____
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 ofa member or manager in a limited liability company, or interest of a berieficiarybf a trust, estate or other similar entity. If none, state "None." NOTE: Pursuantto Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional inforhiatiori from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address ^ Percentage Interest in the
Disciosing 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?
[JYes jtffo
If yes, please identify below the name(s) of such City eledted official(s) and describe such relatiottship(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 arid 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 ofthe relationship; and the total amount of the fees paid orVestimated to be paid. The Disclosing Party is hot 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 art 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
Nkme''(ihdicate;;whether Business Relationship to DisclosingPatty Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid of estimated;)NOTE!
tb be retained) lobbyist, etc.) "hourly rate" or ut.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
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?
U Yes [ ] No wNo person directly orindirectly owns 10% or more of the
7 Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of ail support owed and is';the person in compliance with that agreement?
□ Yes UNo
B. FURTHER CERTIFICATIONS
L Pursuant to Municipal Code Chapter 1-23, Article I ("Article I"j(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 with the City, then the Disciosing 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, of placed under supervision for, any .c-flihinai offense involving actual, attempted, or conspiracy to Commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer dr employee ofthe City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies tb 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 IliB, 1,-of this EDS-:
a. ate not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government',
b. 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 j udgment 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 fedefal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification of destruction of recofds; making false statements; or receiving Stolen property;
C< are not presently indicted for, of criminally dr civilly charged by, a go vernmental entity (federal, state or local) with committing any of the offenses set forth in clause B,2,b. of this Section V;
d. 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
e. 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 eontractdf dr 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"); ■ahy "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 controi 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 ihe 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 of entity that directly or indirectly controls the Contractor, is controlled by if, 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 ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
PageS of 13
Neither the Disclosing^arty, nor any 'Contractor,, nor any Affiiiated Entity of either the Disclbsing Party or any Contractor nor any Agents have, during the five years before the date thisEDS is signed, or, with fespectib a Cohtractor, an Affiiiated 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:
a. bribed or attempted tb bribe; or been convicted or adjudged guilty of bribery or atterhpfing 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;
b. 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
c. 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
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in of 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 ofthe United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
.5, Neither the Disclosing Party fibf ahy- Affiliated-Entity is listed on any ofthe following lists maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the BiireaU 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. ' V ' ;
6. the Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
MA _
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.
Ct CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that the Disclbsing Party (Check one)
a "financial institution" as defined in. Section 2*32-453(0) ofthe Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will hot become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affiliates is, and none of 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 if or ahy of its affiliates (as defined in Section 2-32-455(b) bf the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
If the letters "NA," the word "None," or no response appears on the lines above, if will-be Conclusively presumed that the Disclosing Party certified tb the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms; that are defined in Chapter 2-156 ofthe Municipal Code have the same meanings when used in this Pari 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 entity in the Matter?
I J Yes ^No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and 0.3. If you checked "No" to Item D.l., proceed to Part E.
Page 7 of 13
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted; rid City elected official or employee shall have a financial interest inhis ortier bwfi name or iri the nariie of ariyotherperson or entity in the purchase of any property mat(i) belongs to the City, or (ii) is sold for faxes of 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?
[jYes []No
3. if you checked "Yes" to Item D.L, provide the nattiestand business addresses of the City Officials or employees having such interest and identify the nature of such intefest:
Name Business Address Nature of Interest
4. The Disclosing Party further certifies that rio prohibited, financial ittterest 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 comply with these disclosure requirements may make any Contract entered into with the City in connection with the Matter voidable by the City.
_yvj The Disclosing Party verifies that the Disclosing Party has searched any and all records of me Disclosing Party arid any and all predecessor entities fegarding fecbfds of investments of profits from slavery Or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided Coverage fof 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:
Page 8 of 13
SECTION VI ~ CERtiFldAtlONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter Is federally funded, complete this Section VI, If the Matter Is flbt federally funded, proceed to Section VII. For purposes of this Section VI, tax credits llldcated hy the City and proceeds of debt obligations of the City are not federal ftmdihg,
A. CERTIFICATION REGARDING LOBBYING
1. List be|dw the names of all persons or entities registered under the federal Lobbyihg; Disclosure Act of 1995 who have made lobbyihg Contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the tines above, or ifthe letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons of 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, 1. above for his or her lobbying activities or to pay any person or entity to influence dr 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--------.....-----------
3 , The Disclosing Party will submit an updated certification at the end of each calendar quartef dn which there occurs any event that materially affects theaccuracy ofthe statements and ihfoftnatidn Set forth in paragraphs A. 1. and A.2, above,,
/
4. - 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 ah organization described in section 501(c)(4) of theTntefnal Revenue Code of 1986 but has not engaged and will not erigage in "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal irt 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.
Page 9 of 13
B. CERTIFiCAT ION 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 of in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[JYes [JNo 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 GFR Part 60-2.)
[ J Yes [ 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?
[JYes [JNo
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause7
[JYes [JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:
SECTION VII- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE ■
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any cdntfact 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.
B. 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. arid may also be obtained from the City's Board of Ethics, 740 N.
Page 10 of 13
Sedgwick St, Suite 500, Chicago, IL 60610, (312) 744-9660. the Disclosing Party must comply fully with the applicable ordinances,
C. 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 Clty. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
Di 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 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
the Disclosing Party represents and warrants that:
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 Hsted 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 ofthe 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.
Page 11 of 13
NOTE: if the Disclosing Party cannot certify as to any of the items in F.l ., FI2. or F.l above, explanatory statement must be attached to this EDS:
an
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.
'■$/l64vm)£ b/£r?e/d-T> %s/<*£/*y /ka/A/^ ££-d (Print or type name of Disclosing Party)
By- .^X&fe
fSignhere) is
(Sign here)
(Print or type name of person signing)
(Print or type title of person signing)
Signed and sworn to before me on (date) "?■//%/'// ai (LOO&L County, JlZ fttateV.
Notary Public.
Commission expires: _f/B//^
Official Seal Maureen R Pruniy Notary Public Stats of Illinois My Commission £xpir«a:08/G3/2b14
Page 12 of 13
ECONOMIC DISCLOSURE STATEMENT AND AFFtDAVlt
APPENDIXA
V
FAMILIAL RELAtlONSHIPS VVITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS,
This Appendix ia to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7 J percent. It is hot to Be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Sec^ or any "Applicable: Party*' orany Spouse or Domestic Partner thereof currently has a 'Tamilial relationship'' with any elected city official or department head. A "familial relationship'' existsif, as of the date this EDS is signed, the Disclosing Party of 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 dr 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) allexecutive officers of the Disclosing Party listed in Section II;B.l.a.,if-the Disclosing Party is a eofpofation; all partners ofthe Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited'partners of me 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 ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal-officers"means the president, chief operating officer; executive director; ch^ 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?
t JYes ^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 ofthe 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
A. Legalhame of the Disclosing Party submitting this. EDS. Include d/b/a/ if applicable:
Check ONE of the following three boxes:
Indicatewhether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. M 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: 7&&&/n&i>-7h?<H-N0l>06/e&tic.
OR
3,1] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:__,
B. Business address ofthe Disclosing Party:
C: Telephone: 3■ ¥¥J /6>dd Fax: £/£ - W7 dS/C> Email;jVrh. DA ah OS^kd)
------ y D -thermal'aM^<tMo7<Lpm
D . Name of contact person: S/m- VA £>N \)&A~T_
fi. 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):
G. Which City agency or department is requesting this EDS? t$d£z /(L£>0 \
If the Matter is a contract being handled by the City*9 Department of Procurement Services, please complete the following:
Specification #_.______ and Contract #___.,
Ver, 09-01-10
Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTEREST'S
A. NATURE OF THE DISCLOSiNG PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Persbri
[ ] Publicly registered business corporation [ ] Privately held business corporation [ ] Sole proprietorship 1 ] General partnership [ ] Limited partnership ;[ ] Trust
}4 Limited liability company
t j Limited liability partnership
t j Joint venture
t ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
tJYes []No t ] 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 tlNo [ 1 N/A
B. IP 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 nosuch members, write "nomembers."" For trusts, estates or other similar entities, list below the legaititleholder(s).
If the entity is a general partnership, limitedpartnership, limited liability company ^limited liability partnership or joint venture, list below the name arid title of each general partner, managing member, manager or any other person oi 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
l__L
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% ofthe Disclosing Party, Examples of such an interest include shares iri: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 ofthe 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
Disciosing Party /
fl)MMAe& &9i-&£T ^A/a'e,i ttfc/StAftoS /fL ll*(L_6&.Q/ /0
SECTION UI - 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?
[JYes
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 ofthe 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 either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to'Dl9eid'sin'g'.P_'rty; Fees (indicate whether retained of anticipated Address (subcontractor, attorney, paid or estimated.) NOTE;
to be retained) lobbyist, etc.) "hourly rate" or "tb.d." is
notan acceptable fespbhse.
(Add sheets if necessary)
^fcheck here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V> CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2=92-415, substantial owners of business entities that contract with the City,must remain in compliance with their child support obligations throughout the contract's term.
Has any person 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 cbmpeterit jurisdiction?
[jYes []-No tTNbP^on-'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 ail support owed and is the person in compliance with that agreement?
[]Yes [JNo
Bi FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article i")(which the Applicant should consult fof defined terms (e.g., "doing business") and legal requirements), ifthe 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; bf placed Under supervision for, ariy criminal offense involving actual, attempted, or conspiracy tb cbmtnit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer of employee of the City or any sister agency; and (H) the Applicant understands and acknowledges that complilnce with Article 1 is a continuing requirerhent for doing business with the City. NOTE: If Article I applies to the Applicant,^ the permanent compliahce timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
2. The Disciosing Party and, if me Discldsihg Party is a legal entity, all of those persons or entities identified in Section II.B - U of this EDS:
a. are hot presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal^ state or local unit of government;
b. 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;
c. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offertses Set forth in clause B.2,b. of this Section V;
d. have riot, 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
e. 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 atty 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 of 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 indifectly: controls the Disclosing Party, is cotttrdlled by the Disciosing 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 managernerit, ownership,; of 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 ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent dr employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of if espdrisible official ofthe Disciosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disciosing Party, nor any Contractor, nor any Affiliated Entity of either the Disciosing Party or any Contractor nor any Agents have,; during the five years before the date mis EDS is signed, or, with respect to a Contractor, an Affiliated Entity, Or an Affiliated Entity of a Cohh9Ctor^urih'g#«;itlv«ryea'r8 before the date of such Contractor's or Affiiiated Entity's contract or erigageriteiit in connection with the Matter: ' ~
ai bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer of employee of the City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
b. agreed or colluded with other bidders or prospective bidders, or been a party to any Such agreement, or been convicted of 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 r
c. 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
d. violated the provisions of Municipal Code Section 2-92-610,(Living Wage Ordinance).
4, Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting With any unit of state of local government as a result of engaging in or being Convicted of (1) bid-rigging in vio lation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; of (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
- 5. Neither the DiscidsingsParty 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 Bufeau 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.
6. The Disclosing Pafty understands arid shall compiy with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Mpi_ . _
Page 6 of 13
If the letters "NA,'' the word "None," or nd reSpdase appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
C. CERTIFICATION OF STATUS ASTTNANGlAL INSTITUTION
1. The Disclosing Party certifies that the Disclosing Party (check one)
£ 1 is
is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
" We are not and will not become a predatoryTender as.defined in Chapter 2-32 of the Municipal Code. Wefurther pledge that hone of our affiliates island 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 toss of the privilege of doing business with the City."
If the Disciosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-435(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): \ ,
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 2-15 6 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 of employee of the City have a financial interest iri his of her own name or in the name of any other person or entity in the Matter? .
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.
Page 7 of 13
,2. Unless sola pursuant to a process of cornjetitive bidding, or otherwise permitted, ho City elected official or employee shall have a financial interest in his or her own name or ih the name of any other person or entity in the purchase of any property thai (i) belongs to the City, orfii) is Sold for taxes of assessments, brftii) is sold by virtue of legal process If the suit of the City (collectively, ''City Property Sale")* Compensatioh 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; Matterinvolve a City Property Sale?
[JYes [ ] No;
3. If you checked "Yes" to Item D.l ., provide the names and business addresses of the City officials or employees having siicK interest arid identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Party further,certifies that nd 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 comply with these disclosure requirements may triakeany contract entered Into with the City irt connection with the Matter voidable by the City. ;
^ 1. The Disclosing Party verifies that the Disclosing Party has searched any arid 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 Disclbsing Party verifies that the following constitutes full disclosure of all such records, including the nam es bf any arid all slaves or slaveholders described in those records :
Page 8 of 13
SECTION VI - CERTIFICATIONS F0R,FEDIILAL1DY FUNDED MATTERS
NOTE: if the Matter il federally funded, qornplete this Section VI. If the Matter Is hot federally funded, proceed to Section VII, For purposes of this Section VI, tax credits allocated by theCity and proceeds of debt obligations ofthe City are not federal funding,
A. CERTIFICATION REGARDING LOBBYING
I . List below the names of all persons or entities registered wider the federal Lobbying D isclosure Act of 1995 w;hp have made lobbying contacts dn behalf of the Disclosing Party with respect to the Matter; (Add sheets if necessary):
(If no explanation appears of begins oh the lirtes above, or if the letters "NA" of if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons of 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 ahy federally appropriated funds to pay any person of entity listed in Paragraph A. 1. above for his df her lobbying activities or to pay any person or entity to influence of attempt to influence an officer or employee of ahy agency,: as defined by applicable federal law, a member of Congress, ah 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.....
'3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A.l. and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section / 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal; Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l, through AA .above from all subcontractors before it awards arty 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.
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B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations f equire the Applicant arid all proposed Subcbritractbrs to submit the following informafiOrt with their bids of in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[JYes tl'No 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.)
[]Yes []No
2. Have you filed with the Joint Reporting Committeei the'Director of the Office of Federal Contract Cdmpiiafice Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[JYes [JNo
3; Have you participated in any previous contfacts dr subcdrifracts subject to the equal opportunity clause?
[JYes [JNo
If you checked "No" to question 1, or 2. above, please provide an explanation:
SECTION VII - ACKNOWLEDGMENTS,CONTMACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that-:
A. The certifications, disclosures, and acknowledgments contained in this EDS Will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and 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 ort which this EDS is based.
B. 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 sCeking-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.
Page! Oof 13
Sedgwick St., Suite 500, Chicago, IL 60610; (3T3) 744-9660. The Disclosing'Party mu«cotfiply'-fiifiy with the applicable ordinances,
C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreefrieht in connection; with which it is submitted may be rescinded of be void or voidable, and the City may pursue iafiy femedies under the contract or agreement (if hot rescifided of void), at law, or in equity, ihcludihg terminatirig the Disclosing Party's participation ih the Matter and/or declining to allow the Disclosing Patiy io p^icipaie 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.
D . It is the City's policy to make this document available to the public on its Internet site arid/br upon request. Some or all of the information provided on this EDS and any attachments tb this EDS may be made available to the public ohthe Internet, iii response to a Freedom of Informatibn Act request, or otherwise, By completing and ;signihg ^ Party waives and releasesany possible
fighits or claims which it may have against the City in connection With the public release of informatibn contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided ip this EDS must be kept current. In the event of changes, the Disciosing 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. NOTEi With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERM ANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
' ) , ,.
F. l. The Disclosing Party is not delinquent ih the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclbsing 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, sewef 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 fedefal 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 front 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.
Page 11 of 13
NOTE: If (he Disclosing Party cannot certify as to of the i tems in F.I., F.2. or Fi- above, an explanatory statement must be attached to this EDS. ,
CERTIFICATION
Under penalty Of perjury, the person sighing below: (lj warrants that he/she is authorized to execute" this EDS and Appendix A (if applicable) bri 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 arid complete as of the date furnished to the City.
(Print or type name bfDisclosihg Party)
(Print or type name of person signing)
(Print or type title of person signing)
Notary Public.
Page 12 of 13
city ofchicago economic: discix3sijrewatement a^d affidavit
Ap#eMhXa
FAMDLIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
this Appendix is to be completed only by (a) the Applicant, and (h) any legal entity which Has a direst 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 2454-015, 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 dr any city department as spouse or domestic partner dr as any of the following, whether by blood or adoption: parent, child, brother or.sistef; aunt or uncle, niece or nephew, grandparent, grandchild, father-in-iaw, nidthef-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 Disclbsing Party listed in Section IliBi la., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general parmefship; all general partners and limited partners5■of the DisclosingParty, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclbsing Party is a lirnited;liability company; (2) all principal officers of the Disclosing Party; and (3) arty person having more than a 7.5 percent ownership interest in. the Disclosing Party. 'T-rineipai officers" means tile president; chief bjrierating officer, executive director, chief financial officer, tf easufef or secretary of a legal entity or any person exercisifig 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?
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 familiar relationship, and (4) the precise nature of such familial relationship.
t JYes
\
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT ANb AFFIDAVIT
8E<Ci?ION I GENERAL INFORM ATION
A. Legal name ofthe Disclosing Party submitting this EDS, Include d/b/a/ if applicable: John Hancock Lif e insurance Company (U. S .A >, successor by merger to John Hancock Life Insurance Company
Check ONE Of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: 1. [ J the Applicant
2. [if a legal entity holding a director indirect interest in the Applicant. State the legal name ofthe Applicant in which the Disclosing Party holds an interest; ftlfre Thermal Technologies,inc.
3. [ ] a legal entity with a right of control (sec Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:, . .. _
B. ;B^e^ad%es*-of-tlie- Disclosing Party: 197 Clarendon street, C-3
Boston, MA 02116 ?.;...
C. telephone: 617-572-9245 Fax: 617-S72-9269 Email: j^liae^jatobek.com
D. Name of contact person: John T. Wallace
E. Federal Employer Identification; tfp* (if you have onelJ)|P_______-^
F. Brief description of contract, transaction or 6'thef undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Exterj^ipn of City Use Agreement (Amendment #26) _ ,
G. Which City agency or department is requesting this EDS? PPS/CPOT
If the M atter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification# _ arid Contract #_
Ver. 09-omo Page 1 of 13
SECTION II *- DISICLOSURE OF OWNERSHIP WT^RIBSTS
A. NATURE OF THB DISCLOSING PARITY
1. Indicate the nature
[ ] Person [ ] Limited 'liability company
[ t- Publicly registered business corporation [ ] Limited liability partnership
[ ] Privately held business corporation ( ] Joint venture
[ ] Sole proprieto [ ]}^dUt^if^fit'Mtpt>ti3iti6n
[ ] General partnership (Is the not-for-profit corporation also a 501(cX3))? [ ] Limited partnership [JYes? I] No
[ ] Trust XJ\dth'er(pie'afe^ecify)
2. For legal entities; the state (or foreign country) of incbl^oratiOn or organization; if applicable:
3 . For legal entitiesi riot organized in the State of Illinois: Has: the Organization registered to do buskers in tile Ste
[% Yes UNo pN/A
B. IF THE D'lSCL^SiHlfrP'ARTlif IS A LEGAL ENTITY:
1, Lisfbelciw the full names and titles of all executive officers and all directors of the entity. NOTE^ also list belWl^neni'beSi ff4j$?$pG& at^re'pl'lh*Hiiesr: W"
there arenp such members, Write "tip members." For tfusts, estates of other sirriilaf entities, list belOw .Are legal titleholder(8).
Ifthe entity is a general partnership, limited partnership, limited liability; company, limited liability partnership or joint venture; list below the riariie arid title of eadh genera:! partner, managingmember,: manager of any other person of entity that controls the day-td-day management ofthe Disclosing Party. NOTE: Each legal entity: listed below must submit an EDS: on its^wn behalf
Name Title Please see attached
2. Please provide the following information cohcefriirig each person of entity having a direct or indirect beneficial interest (including ownership) in excess: of 7.5% ofthe Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13
intbrbst <>f a M^$$-j&r- maiiai#r $t:a Hmited liability company, or interestof a beneficiaryof a trust; ^ta1#:djf-^er:i^'Uiif> entity. If nOne, state *N one." NOTE: Pursuant to Section 2454*030 of the Municipal Godo of OW infdfMatibri from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage interest in the
Manulife Financial 2^ Bloor St. East, Disclosing Party
Corporation Terbfjfe;6y ohtario M4W IBS ioo% (indirect)
* Canada ' ' : ;.
John Hancock Holdings (game aa above! 100% (.^direct? (fielaware) LLC
SECTION IH - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2>I 56 Of the Municipal Code, with any City elected official inThe 12 months before the date mis EDS is signed?
[] Yes $No
If yesy please iden ^ felatiprjiship(s): 7
SE^t^ONTV ^DISCLOSURE OF SUBCONTRACTORS AND OTHER^R^AlN
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 Disclbsing Party has[retained or expects to retain in connection with the Matter, as well as the nature of the felationship, and the total arabuht of the fees paid or estimated to be paid. The Disclbsing 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 undertake to influence any legislative or administrative actibnibn behalf of any pefsorior entity omer than: (l) a not-fo
himself . "Lobbyist5" also means any person or entity any part of whose dutieias an employee of 'a&o&efindudesvndeTtaktitg to mfluence any legislative or a:djnihi8tfative-a^tiptL-.
if the Disclosing Party is uncertain whether-adisclosure is required under this Sectipn, the Disclosing Party must either ask the City whether disclosure is required of make the disclosure.
Page 3 of 13
Name (indicate whether Business retained or anticipated Address to be retained)
Relationshipto Disclosing Party (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NQT*1; "hourly rate* or is not an acceptable response.
(Add Sheets if necessary)
[ $Check here ifthe Disclosing Party has not retained, nor expects to retain, ahy such persons or entities.
SECTION V ~ CERTIFICATIONS
A, COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92*415, substantial owners of bus iness 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?
[jYes
[ ] 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^paymehtof all sup^pbrt owed ahd^ is the person in compliance with that agreement?
[JYes
[] No
B. FURTHER CERTIFICATIONS
" - / '
1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article l")(which the Applicant should
consult for defined terms (e.g., "doing business'*) and legal requirements), if the Disciosing Party
submitting this ED S is the Applicant arid is doing business with; the City, then the Disclbsing 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 entitles identified in Section II.B.l pfthis EDS:
a. are-riot presently debarred, suspended, proposed for debarment, declared ineligible or Voluntarily excluded from any transactions by any federal, state or local unit of government;
b. 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;
c. are not presently indicted for, Or Criminally or civilly charged by, a govefnmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
d. 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
e. have hot; within a five4-yearperiod 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 violation^instftu^ ^ede^^gpyern^ejtt^^an^ state, or any dther Unit of local government.
3. The certifications utsubparts 3,4 and 5 concern:1-»the Disciosing Party;
any "Contractor" (meaning any contractor oi subcontractor used by the Disciosing 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 arid equipment;common use of employ ees; or organization of a busmess entity fott^^^ ineligibility of a business entity to do business with federal or state or local goverttmeriti ificludirig the City, using substantially the same management, ownership, or principals asi theirieligible 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 persori of entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Eritify 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 theDisclbsirtg Party, any Contractor Or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclbsihg Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party Of 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:
a; bribed or attempted to bribe, or been convicted br adjudged guilty of bribery of attempting to bfibe; a public dffieef of employee of the City, me State of Illinois, or any agency of the federal governnient Of of any state or local government in the United: States of Ajmer ica, in thatofficer's; or emplpyee's officiai capadity;
b. agreed of colluded with other bidders or prospective bidders, orbeen a party to any such agreement, or been convicted of adjudged guilty of Agreement of collusion among bidders of prpspective bidders, in restraint of freedom of competition by agreement to bid a fixed price or Otherwise; or
c. 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
d. violated the provisions ofMunicipal Code;$}&ti$h2-9%y-6lO-^LWmg^ia^Ordiitance).
4. Neithef the Disclosing Paffy; Affiliated Entity or Contractor, or aiiy of their employees, officials, agents or partners, is barred from contracting wi th any*urtit of state of local governmentas a result Of cmgagmg in Of b|ih^ep'a[vibted of CI) bid-rigging m violation of 720 ILCSI 5^33E>3; (2) bid-rotating in violation of 720 ILCS 5^33 E-4^ or (3) any similar offense of any state or ofthe tilnited States of America that contains the same elements as the offense df bid-rigging or bid^rdtatihg.
5. Neithef the Disclosing Party nor any A ffiliated Entity is listed on any of the following lists thaiikiife^'^y.lhe- CKfljjb.d of Foreign Assets Control of the UjS, Department of the Treasury or the Bureau of Industry and Security ofthe U.S. Department of Gdmmefce Or their successors: the Specially Designated Nationals List; the Denied Persons List, the Unverified List, -the Entity List and the Debarred List.
6. The'Disclosing Party understands and shall comply with the: applicable requirements of Chapters 2-55 (Legislative Ihspecfor General), 2-56 (Inspector General) and 2^f 56 (GoVefhmental Ethics) of the Municipal Code.
7. If the Disdlosihg/Party is unable to certify to any of me above sta
Certifications), the Disciosing Party must explain below:
The cerfcificaBioris in subparts 2,3 and 4 above pertain solely to the
DiscToslrig Party and those persons and entities that, directly or indirectly, control thepjgcipsing Party. , _
Page 6 of 13
If the letters "N A,- the word "NOrfe;"or no response appears on the lines above, it will he conclusively presumed that the 0
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that the Disclosing Party (check One) |^is {J is not
a^ hf|hancial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing; Party ISl afinancial hjsiinjfiptt,.:tiieii .the Disclosing.Party pledges:
wWe*afe hot and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. $e further pledge that none of our affiliates island n<?ne of therii. wiU become,: a predatory lender as defined in Chapter 2-3 2 of the Municipal Code. We Understand that becoming a predatory iendef: Or becoming att affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."
If the Disclosing; Party Is unable tp make this pledge because it or any of its affiliates |as defined in ^^a^-i'2:«4^(D') of the Municipal Code) is a predatory lender within the meaning^pf^h^ptlr I|3^ftle Municipal Code, explain here (aM^
N/A_ ; . .... .. " "" "" 7 .,. -
If the letters "N A," the word "None," or no response appears on the lines above, it wlllbe; conclusively presumed that the Disclosing Party certified to the above statements,
D, CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any wofdsor terms that are defined in Chapter 2-156 of the Municipal Code have the, sarne meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee pf theOity have a financial interest in his or her own name or ih the name of any omer persdh Or entity in the Matter?
I J Yes 15 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.
Page 7 of 13
2; Unless sold pursuant to a process of competitive bidding, or Otherwise permitted, no City elected official or employee shall have a financial ihterest in his or her own name or in the name of any other person of entity in the purchaserof any property that (i) belongs^ th£ City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suitof the City (collectively, "City Property Sale"). Coni^dnsatidh\for'p^6pe'ffy taken pursuant to tn'#GityTs^mih^t\domain'power does hot constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
I] Yes [JNo
3. If you checked "Yes" to Item D. I., provide the names and business addresses of the City officials or employees having such interest and identify the nature: of ^^Mtejr^
Name Business Address Nature of Interest
4. the Disclosing Party further certifies that no prohibited financial interest ill the Matter will be acquired by any City^^ ofMcial or employee.
B: CERTIFICATION REGARDING SLAVERY ERA BUSINESS!
Please check either 1. of % below, if the Disclbsing Patty checks 2., the Disciosing Parry must disclose below of-in ah attachmeht to this EDS ali ihfbirma'tidn requir^%:pianigf^iii'X Failure to cbmply with these disclosure requirements may make any contract entered into With the City in connection With the MatterJ Vpidable by tHb City. * ■
X j. 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 of profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveho lders thatprovided 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 ih step \ above, the
Disclosing Party has foundrecords of investments of profits from slaveiy or slaveholder insurance policies, the Disclosing Party verifies that the following constitutes full disclosure of atf such records, including the names of any and all slaves Or slaveholders described in those records:
Page 8 of 13
SECTION VI-CERTIFICATIONS
NOTE: If the Matter !* federally funded, complete this Section "VI. If the Matter Is not federally funded, proceed to Section VU. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt qbligatiopsi of the City are not federal funding.
A. CERTIFICAf IONREGARDING LOBBYING
I, List below1 the namesof allpersons or entities registered under the federal Lobbymg Disclosure Act Of 1995 who have made lobbying contacts on behalf of the Disclosing Party With respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "N A" or if the word "None" appear, it Will be cbhcUisively presumed that the Disclosing Party means that NO persons or entities registered Under the LOb lobbying contacts on behalf^f the
Disclosing Party with respect to the Matter.)
2. The pis^losing Party has not spent and will not expend any federally appropriated funds tq pay any person orentity listed in Paragraph A; 1. above for hisepr her jr^
person or entity to influence or attempt to influence an officer oremployee^ of ' any agency, as iSefihed by applicable federal law, a member of CbngreSSi an officer Or employee*bfCongress, 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 cpope^tlve agreerheht, or id ejttehd^ cbntinue, f eheWj amend, orMqdtt^^ny federally funded contract j grant, ioarij bf cobperativeagreemertt.
3. the Disclbsing Party will submit an updated certification at the end of each calendar quarter in which there Occurs any event that materially affects the accuracy bf the statements and informatibn set forth in paragrapns A.l. and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not ah organization described in section 501(c)(4) of the;Internal Revenue Code bf 1986; or (ii)it is an organi^atibn described in section
id 1(c)(4) of' the Internal Revenue Code of 1986 but bas not engaged and will not engage in "Lobbyihg Activities".
5. If the Disclbsing Party Is the Applicant, the Disclosing Party must-obtain certifications equal in form and substance to paragraphs A-1 through A.4. abovefrom allsubcbntfactors before it awards any -a«beoii^#t.ah^;the Disclosbig Party must maintain all such subSbritfactbrS' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.
Page 9 of 13
B. CERTIFICATION REGARDING EQUAL EMPLOYMENTOPPORWNITY
If the Matter is federally funded, federal regulahohs require the Applicant and all proposed subqpntfactprs to submit the following infoMatiqitw^ at the outset of
negotiations.
Is the disclosing Party the Applicant?
[ ] Yes []No If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federalregulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] No v
2. Have yqu fded with the Joint RepbrtMgCommittee, the
Cphtract Cornpliah^ Equal Employment Opportunity Commission all reports due
Under the applicable filing requirements? [JYes [j No
3. Have, you participated in any previous contracts or subcoutraci|t subject to the equal opportunity clause?
f 1 Yes []No .
ifyouiChecked"No;'tqquesti
SiOtlOfo VII- AC&NOWLEDGMENTSj CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
TheDisclosing Party underetands and agrees that:
A\ the certifications, disclosures, and aclaiowiedgments contained in this EDS will beeb contract or other agreemenf between the Applicant and the City ih coptiectibn with the Matter, whether prbcureih^ of qthef Ci^ctiOp^a^^hinterial teduceinents to the Cityls execution
qf anycontract bf taking other action with respect to the Mattef. the Disciosing Party understands that It mustcqmply with all statutes, ordinances, and regujatiqn| on which/this EDS is based.
B. The City's Gcvernmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municijpal Code, impose certain duties and obligations oh 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.cltvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Page 10 of 13
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully .with'the^pplicable:ord'ulaiic'esi
C If the City determines that any information provided in this EDS is false, mcbmplete or inaccurate, any contractor other agreement in conneetion 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 arid/or declining tb allow the Disclosing Party to participate in other tfansactions with the City. Remedies at law for a false statemerit of material fact may include incarceration and art aw|ird to the Cjty of treble damages.
D. It is the City's policy to make this document available to the public On i^^^^^^^i^ti.iiipon request. Some or all ofthe information provided on mis EDS and any aftachmehts tb this EDS may be made available to the public on the Internet, in response to a Freedom of InfOrinaubnAct iequest, or otherwise. By completing and signing this EDS, the Disclo.sing-Pai^>w^eS'ant.re^^'ajiy pdssible rights or claims which it may have against the City in connection with the public release bf information contained in this EDS and alsb authorizes the City tb 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 tb the time the City takes action on the ^ is a cbhtract being handled by the City's Department of Procurement Services, mc
Update this EDS as me contract requires. NOTE: With respect to Matters subject to Article! bf Chapter 1 -23 of the Municipal Cbde5(imppsing PERMANENT INEI^GIB
offenses), the Informatibn providedhereiri regarding eligibility must be; kept current|fc>r a Ipngerperiod, as required by Chapter i ^23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
P. 1. The Disclosing Party Is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclbsing Party Or its; Affihated Entities delinquenfin 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 Parry 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/subcontractorshired of to be hired in connection with me Matter certifications equal in form and substanceto those in F.l. and F.2. above and Will not, without the prior written consent ofthe City, use any such contractor/subcontractor that does not provide such certificatibnis or that the / Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
Page 11 of 13
NOTE: If we Discloslng Party cannot certify as to ^pt^ii^m'm^X^S^-PX above, an explanatory statement must be attached to this EDS.
G$KT1F1CATI0N
Under penalty of perjury, the person signing below: ( l ) warrants uiat he/she is auth
this EDS and Appendix A (if applicablejen behalf ofthe Discld^in^ and (2) warrants mat All
e^fi^onyW;^at^iae|its contained in this EDS and Appendix A (if applicable) are true* aecuhjte
ahd complete as of Uie date furnished to the City. JohnHahCbck Li£einsurance Company (018 ^A.) >
successor by tngt^er co John HancocK Life Insuirahce: Company
(Print or type name of Disclosing Party)
^ighherel john C.-g\.Aridatsbn
(Print or type flame of person signing) (Print of type title of person signing)
Sighed and swornto before me on f datelyfe y^i ry ye-- ^ y*n« a; at Suffolk , County. Gommoni^^^^^s^^u^efffea
Notary Public.
Commission exdtfe
« ^^^^ mi,tmiUllx
Page 12 of 13
CITY OF CHICAGO ECONOMIC MS^LOSIJM ^ AFFIDAVM
APPENDIXA
FAMILIAL RELAtlONSliiES WITH ELECTED CITY OFFICIALS AND DEPAFtTMJENTMEADS
This Appendix is to be completed Only fcy (a) the Applicant, arid (b) any legalehttr|rwhteh has a direct ownership interest in theApplicant exceeding 7.5 percent. It is not to be completed;|iy any iegillentity which has only an indirect ownership interest in the Applicant.
Under^ Municipal Code Section2-154r0l5i the Disclosing Parly most disclose whether such Disclosing Party Of any "Applicable Party" of any SpduSe of Domestic Farmer thereof currently has a "familial felatidnship" with any elected city official or department, head. A "familial relationship" exists if, as Qf-thed^e^^6J0$'fS'-signedi the Disclosing Party or any applicable Party" or any Spouse or Domestic Parmer thereof is related to the mayor, any alderman, tW.ci^cle^%the'ej|^ treasurer of any city department head as spouse of domestic partner or as any of the following, whether by blood or adoption: parent, child, ^
niece or nephew, graitdparehL .gi^^hlldi^i^f-iiN^ mother-aa-laW, sdh-m-law, dauj^terrin^iaw; stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sisfef;
^Applicable Party" means; listed itt Section n.Bvl;ai; ifthe
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general parriKr^ip; all generate DisclpsingPaflty, if
partnership; all managers, maflagmg^m^ membera of me Disclosing Party, ^$i0^o^^efy is a
limited liability company, (2) alipfiriclpai^officers of the Disclosing Party; and (3) anypersbh than a 7.5 percent p^ officers'' ^e^^.^^deh^eln^f
operating officer, executive director, chief* financial officer, treasurer or secretary o|ailegatenth^ exercising similar authority.
Does me Disclosing Party or any "Aprilicable Parry'' or any Spouse Or Domestic ^ai«aer:thetieoff>ei»iently have a familial relationship*' with, an-efec^'ciQr.official of department head?
{ ] Yes ; t ^ No
If yes, please identify below (1) thenafnc and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title of the elected city official br department head to whom such personhas a familial relationship, and (4) me precise nafere of such familial relationshipi
Page 13 of 13
JORN Hancock life insurance compaiw (u.s.a.j
CHAIRMANAtifi PRESIDENT James R. Boyle
Jonathan Chiel
DIRECTORS
James R. Boyle Thomas BorshofP Paul M. Connolly* Steven Pinch faith AnnFifemihg* James D. Gallagher Scott s! Hartz Rex Schlaybaugh, Jr.* John G. Vrysen
EXECTmVtrf vicE PRRSfhtiiiVTS
Marc Cbstantim*
Steven Finch
James D. Gallagher
Scott S. Hartz
Peter Levitt
Katherine MacMillan:
Steph^Ri wMtftmi'
Hugh McHaffle
and Chief Investment OffinerUS Invretmrnx,
Bob Diefenbacher Peter Gordon Allan Hackney
Gregorycpaclt Lynne Patterson Craig R. Raymond Diana L. Scott R. Se^liezzi ftice^spc'a, '*|o%lfif'' ■'■ _■■.■*. - -/Bfdoks|^n|j|i' . ■Jdfiii'Gvivlyleh
VICT PRESENT* EmaiiueisA'Ives John C.S. Anderson Roy V. Anderson Arnold Bergman Stephen J.-Ble win Robert Boyda JolmE.Brabazon
and Chieflnformation dnirpr
and Chief Fiiiancitil drri^r
Chief Actuary & Chief RiskOfffcer
Counsel and Corporate .q^tary
^^0!^ji^^lc^aLQf^^ccrJm'es(n1el1fe
VICEPRESihEtitS (Continued)
George H. Braun
Thomas Bruns
Tyler Carr
Robert T. Cassato
Kevin J. Cloherty
Brian Collins
Art Creel
George Cushriie
John J. Danello
Willma Davis
Anthony J. Delia Plana
Brent Dennis
Robert Donahue
Edward Eng
Carol Nicholson Fulp
Paiil Gallagher
Wayne A. Gates
Anil Gencarclla
Richard Harris
John Hatch
Kevin Hill
E. Kendall Hines
Eugene Xavier Hodge, Jr.
James C. Hoodlet
Roy Kapoor
Mitchell Kannan
Frank Knox
David Kroach
Jonathan Kutrubes
Cynthia Lacasse
Denise Lang
Robert Leach
David Longfritz
Nathaniel I. Margolis
John Maynard
Steven McComu'ck
Janis K. McDonough
Scott A. McFetridge
William McPadden
Maureen Milet
Peter J. Mohgeau
Steven Moore
Curtis Morrison
Tom Mullen
Scptt Navin -
§|na ifebiosi
Prank O'Neill
Jacques Ouimet
Gary M. Pelletier
Steven Pinover
Krishna Ramdinl
S. Mark Rny
Jill Rebman
Mark Rteza
,Inh R. Roke
Andrew Ross
Thomas Samoluk
and Appoinfed Actuary
and chief Compliance rifffrgr & Conmpl ■' ' .;
and Chief Cpmnlianc^
Vice President. Tre^rv
Jonnie Smilh Yiji S. Starr Gaurav Upadfiya Simonetla Vendittelli Peter de Vries Karen Walsh Linda A. Walters Joseph P. Welch
Jeffery Whitehead and Controller
Henry Wong Randy Zipse
ASSISTANT VICE PWRfifKENT*
Joanne Adkins.
Slacey Agretelis
Patricia L. Allison
Eynshteyn Averbukh
Michael Barnes
Jack Barry
Steven Belt
PJ Bellramini
William D. Berthmd
Daniel C. Budde
John W. Byrne
Jennifer Toone Campanella
Suzanne Cartledge
Cynthia A. Cavanaugh
Catherine Collins
Thomas Corrigan
Diane Cronin
Paul M. Crowley
Carol Dauphinee
Lorn C. Davis ; _
foddb. Enirhel ";
Allan M. Ken
Paul A. Fishbin
Michael A. Foreman
Arthur Francis
Donna Frankel
Philip W. Freiberger
Scott B. Garfield
John M. Garrison
Keith Gendron
Gerald C. Hanrahan, Jr.
Teresa S. Hayes
Charles Whitney Hill
Alfredo Iannarilli
fcecep C. Kendircioglu Robert J. Keough
Amie Khondo .Bruce Kinna Carl F. Knowhon Shannon Kole Sally Kwan Bngttte Labreche Brtit Lukcr
ASSISTANT VICE PRESIDENTS (Continued)
Mei-Ling Lee .
Steve L. Legardeur
Scott Lively
Thomas Loftus
Mark Lombardi
Jennifer Lynn
Timothy J. Malik
James Malin
Cheryl Mallett
Robert Maulden
Kenneth W. McCarthy
Elizabeth McDonald
Kathleen E. McDonough \
Reid W. McLay
Pamela Memishian
Catherine Menchin
John P. Monahan
Geoffrey Norris
John O'Connor
Jeffrey Packard
E. David Pemsteim
David Pickett
Michael A. Pirrello
Malcolm Pittman
Sonya Prear
David P. Previle
Peta-Gaye Prinn
Malcolm Quinn
Matthew Rigatti
Kathryn Riley
Josephine M. Rollka
Timothy A. Roseen
Louise Santosuosso
Gordon Shone
Michael L. Short
Susan Simi
Maura Swan
Joan Marie Uzdavinis
HangT. Vu
John Wallace
Sean A. Williams
Sameh Youssef
OTHER OFFICERS
ILLUSTRATION ACTUARY Ryan Charland ~
ASSISTANT SECRETARIES Rosalie M. Calabraro Veronika Chayady Wendy K. Cotellessa Margaret Doyle John H. Durfey Deanna Garland Grace M. O'Connell Kwong Yiu
ASSISTANTTREASURERS Kevin J. McWilliams
* Outside Directors
*=* Designated as responsible for administering the policies and procedures adopted by the Company for its registered separate accounts pursuant to RufeJSa-1 under the Investment Company Act of 1940
May 5,2011
9-
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 ^ GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: Manulife Financial Corporation
Check ONE of the following three boxes:
Indicatewhether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. a legal entity holding a direct or indirect interest in the Applicant. State the legal htirne ofthe Applicant in which the Disclosing Party holds an interest: MDE Thermal Technologies ,Inc.
OR : - -
3. ( } alegal entity with a right of control (see Section H.BrL) State thelegalnameof tliie eritity in which the Disclosing Party holds a right of control:
B. ^ih^s4daressV6ttbe'D'teclpsing Patty: 200 Bloor Street East
'$M^&Oi Ontario M4ft IBS Canada ' .
C. Telephone: 617 -5 72-924 S Fax: 6±7*S^2-^2S9l :.. Email: 3 wat laPe^ j han6°c^ > GO
D. Nambpf corifact person: John. TV Wallace
E. Federal Employer identification No. (if you have one): J^P^HBP . ■ : :;
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 prppertyi if applicable):
Extension of City Use Agreement (Aniendmeiit #26)
G. Which City agency or department is requesting this EDS? pQk/CDOT
Ifthe Matter is a contract being handled by theCity's Department'of Procurement Services, please complete the following:
Specification # . and Contract # ' " ':''"
Ver. 09-0M0
Page! of 13
SECTION II - DI$C!^iJRi OF OWNERSHIP INTERESTS
A. NATURE OF THEiDISCLOSINO PARTY
1. Indicate the nature ofthe Disclosing Party:
( ] Person [ ] Limited liability company
( ^ Publicly registered business corporation f ] Limited liabilitypartnership
(| Privacy ^e|d.buaM|e$a:.«sarpoiatihn [ ] Joint venture
I j Sole proprietorship [) N ot-for~profit corporation
[ ] General partnership- (Is the not-for-profit corporation also a 501 (c)(3))?
[ ]r Limited partnership; I ] Yes II No
[j Trust [] Other (please specify)
2. For legal e^tfti@9V^itate (or foreign country) of incorporation or Organization, if applicable: , Canada
3. For legal entities hot organized in the State of Illinois: Has the organization registered to do business in the
[JYes "" f^No []N/A
B. IF THE DIpLQlSMG(PARTY IS: A LEG AL ENTITY:
I ; List below: the": full flames and titles of all executive pffic^ entity. NOTE; Fpr-n$t$fb^ list below allmember^jf ^whichf^a>e;legaientities. If
there are no such hiembers, write "no members." For trusts, estatesabr Other similar entities, list below the legal titleholder(s).
I^the'enti'^s\a^eiie^ai'^a^e«hi|i limitedpartnership, ipm§p^i limited liability
partnership or joint venture^list below the namejand-'Udd^eatli'-'^l^il papery nWna^tig member, manager or any other per&dn dr entity that controls the day-to-day management of me Disclosing Party. NOTE: Each legal entitylisted below ri^
Name Title Pleafee see attached
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 of j oint venture,
Page 2 of 13
interest ofa member Uability company, oriihterest of a beneficiary of a trust,
estateor otesitttiiaf entity. If nOrte^ state "Nbhe;" NOTE: Pursuant tb Section 2-154-030 ofthe ^ffitnbipiSl^ Ghjcago(*1ta fr£th|^^
Name Business Address Percentage Interest iri the
Disciosing Party
NONE 6 J
SECTTp'N III - BUSINESS RELATIONSlHIPSCITY Elif 6teD OFFICIALS
Has the Disclbsing Party had a "busin^ltfetfolirst^ ali-tfeintedln^hap"fer 2ilSo of ther Municipal eo'dej^titraiiy City elected official blithe 12 months before the date this EDS is signed?
[ ] Yes ■ , 1 DJNo ■ ■. .
If^sj;#^ identify below the name^
.reiatiohiship(s)^- -.^.-i-
----------------^-TlONilV - DISCLOSURE OF SIll^ AND>OTHl^TfcpATl^
The Disclbsing Party rriust disclose the name ah^:bpihe^:address'p|> each" subcpatfactpr; aftbiney, loBbyist; accountant, consultant and any other person or entity whom the Disclosing Party has retained b| expects to retain in connection with the Matter, as well ps the nature of the relationship, and the total amount of the fees paid or estimated fc-.be; paid. .TO#©^|<^ihg Party is not re4uTr^$|6^elps|'-:K employees-who are paid solely through the Dtsclb^hg Patty's regular payroll.
^blb^st"means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity Other to on an unpaid basis^of ($)
htniself "lobbyist'' alsoi means any person or entity^any part of whose duties as an employee Of ahbthertn^
j£tii$^
Disclosing Party must either ask the City Whether disclosure is required or make the disclosure.
Page 3 of 13
W^jfp^ica^yhefller.-■ Business Relationship to Disclosing Patty Pees (indicatewhether tto^$MMt$ip*to$. Address (subcontractor, attorney^ pa id or estimated,) NOTEi
to be retained) lobbyist, etc.) "hourly rate" or Mt.b.d." is
not an acceptable response.
(Add sheets if necessary)
[^Ch^Khere ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTlONi Y* ~ eERTi^IGATlONS
A. COURT-ORDERED CHILD SUPPORT* CO^LL^NCE
Under Municipal Code Section 2-92-415, subsfahtial owner's of business entities that contract with the City rnustrfeiriain in compliance with their child support Obligations throughout the contrabf's: terur.
Has any persbp who directly or ind^
arrearage on any child support obligations by arty Ilhnois courfcof Competent jurisdiction? ^ H ^
tlYes tl'Nd [£Ntfpiikii 'di^Hrpf itidite^tlyflwns-10$ pr.wore-p^the
Disclosihg Party.
If "Yes," has the person entered Into a court-approved agreement for payment of ali support owed and is the person in compliance with that agreement?
[] Yes . []No
B. FURTHMfERTMCATlON . .
1. Pursuant to Municipal Code Chapter i-23, Article I ("Article l^fwhich the Applicant should consult fbridefined^terms (e;gM.^doing business'^andPlegaf requirements), if the Disclosing Party submitting this EDS is the Applicant and is dpBgbusiness With the Cityy then the Diselesing Party certifies as follows; (i) nei^
with, or has admitted guilt of, or has ever been cbhvicted of,;0rplaeed under supervisiohlof, ahy criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury^dishbhesty or deceit against an officer Or employee Ofthe City Or any sister agency; and (ii) the Applicant understands and acknowledges that compliance With Article I is a continuing^ reqtiiiehifeht 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 cbrhphance timeframes in certifications 2 and 3 below.
Page 4 of 13
%, Tvhe i>isclpsmg$&Tty md, if the Disclosing Party is a legal entity, all <Sf-mm-p$i^-6iteia8$M-iaeiitjjRejd|rj Sectioh II.BJ.ef this EI)^
a. a;re^not presently, debarred, *uspehd^ for debarinent, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
b. have hb\wi&iir«a'five*y%p'e4l)d preceding the date of this EDS, been convicted of acriminal offense, adjudged guilty, or had a civil judgment rendered c obtaining, attempting tb obthin, oteperfbiro state or local) transaction or contract under a public transactibh; a violation bf federal or state antitrust statu fraud; embezzlement; theft; forgery; bribery; falsification Or destruction of records; making false statements; or^eeiving«fo»ien-p|!opeiiyi
c. ; are not presently indicted !f^ charged by, a'fgbVei^eMlieiti^-^erli,.
sta te or local) withcbrhmiiting any ofuie offenses setforth in clause B.2.b. Of this Section V ;
d. haye not, within a five-year period preceding the date of this EDS, had'One^r^rtpu'bli^ transactions (federal, state or Ibeai) terminated for cause or default; and
e. have not, within a five-year period the date of this EDS, been cOhy i#ed,;adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil actiOnv includingactions \
/ instituted by the City or by the federal government; any
fState^ or any other unit of Iocaf>gbyerhment.
3. T|he^certificatipnssin
♦ the Disclosing Party; ........-......-
* M^f^on^actorM (meaning any contractor orsubcontractor used by the #isclbBttgiParty in connection with the Matter, iriclud^ limite&tp all persons or legal erttiiies dis^iosed Section tV,. "Disclosure of Su^
any "Affiliated Entity" (meaning; a person or entity that, directly or indirectly; controls the Disclbsing 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, withoutlimitation:
. interiopking management or Ownership; identity of interests amohg family m . .^^^j^eh^fir^pifi use ofemployees; or organization of a business entity followingthe meligibility of a business entity to dd business With federal or sitate or locaj;gbv^m'en^'^iMi|g;' the: City, using substantially the same management, ownership, or principals as the ineligible entity); yiithrjespectto Contractore^met^rmA
indirectly controls the Contractor, is controlled byitydr,- With the Contractor; isiimdercpmrhpn control ofanother person or entity;
any responsible official of the Disclbsing Party, any Contractor or any Affiliated Ehtity or any other official, agent or employee ofthe 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 (coUectively''Agents").
Page 5 of 13
Neither the Disclosing Party, nor anyContractor, nor any Affiliated Entityofeithef lhe Disciosing Party pip any Contractor nor any Agents have, during the five years b$bre ^WW-EM'^sigAed,-oir, witfc respect to a Contractof, an Affiliated Entity, or an Affiliated Entity of a Contractdr during the five years before the date; Of such Contractor's or Affiliated Entity's contractorengagement in connection with the Matter:
a. 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 ahy agency of the federal government or of any state or local government in the*Uttited Statesof Aifiefica, in that officer's of employee'sofficial capacity;
b. agreed or colluded with other bidders or prospective bidders; Of been a party to ahy such agreement, or beeri convicted Or adjudged guilty of agreement or collusion among bidders or prospectiveibid^
otherwise; or
c. 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
d. violated the pravisiohs of Municipal Code Section 2-92*6T0 (Living VV age Ordinance).
4, NeitherihgvDiscipa.hig Party, Affiliated Entity or Contractor, bfMny of their emp^
agents Or partners, is batted front contracting with any unit of state or locai govemmeht as a result of engaging in or being convicted of (1) bid-rigging in viblatioii of 720 ILGS 5i33E>3; (2) bid-rotating in violation of 720 ILOS:i5/33E-4; or (3);any 'similar offense of 'a^y-sta^^'of .ffie'BiottedS tates of America that contains the same elements as the offense of bid-rigging or bid-rotatihg.
5. Neither the Disclpsing Party nor any Affiliated Entity is listedon;ahyOf thefplldwing lists maintained by the Office of Foreign Assets Control of the O.S^I)epa^ehlofA'e'^tleainiiry tiftftfe Bureau of Industry and Security of the US- Department of Cbmmerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List; the Ehtity List ind the Debarred List.
6, The Disclosing Partyvunders^
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-1M (Goverhmehtal Ethics) of the Municipal Code/
7. If, the Disclosing Party is unable to certify to any of the above statements ih this Part B (Further
Certifications), theDisclosing Party must explain below:
The certifications iri subparts 2,3 arid 4 above pertain solely to the
Disclosing Party arid those persona and entities that, directly or indirectly, control the Disclosing Party. _ ,.,,,,, __ _ ■ _
Page 6 of 13
If the letters^ A," the word "None," or ho r^p^i^|^ia1^#tiie- lines abbveiit will b^ pte$j|me^
1. The Diselosing Patty .certifies that .the Disclosing Party (cheek one) (S is [ ] is not
a "fihahcial institution" as defined in Section 2-32-4S5(bj of ft£ Municipal Code,
2. If me Disclosing Par^
"Wears not and Will not become a predatory lender 8^^^id^in-'Ckaftet:'2-32 of the Municipal Cbdei We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined ih Chapter 2-32 of the Municipal Code. 1iVe understand that becoming a predatory lender or becoming an affiliate of a predatory lender hiay result in the loss of the privilege of dbirig business with the City."
if uie Disc losing Party is unable to make>^ (as defifted in
$eeii<m^ 2-32^4^I(b|of the Municipal Code) is a predato^iender wit 2-32 pf the Municipal Code, explain here (attach additionai pages if neGessary):
m/a _...............,K, ,....-; > ■■-
IfJthe letters "NA," the Word "None," or ho re^onse appears on meiiines above, it will be ■ ; conclusively presumed that the Disclosing Party ceffi^
DI CERTIFICATION^ ^ x
Any words; or terms that are de Muoieipal'ddde have the same
rbr&itings when used in this P&rt'.D,
1. In accordance with Section 2-156-110of the.Municipal Godej Does any official br emplOyee pf the 'City have a financial interest in his Of her own name or in the name of any other persbn or ehtity in the Matter? ; ■ t J Yes . [3JNo . -. '
NOTE: If you checked "Yes" to Item D. 1., proceed to Items D.2. and D.3. If you checked "No" to Item D.I., proceed to Part/E.
Page 7 of 13
2. Unless sold pursuanttoa process pfcb^ biMtigr or o)iiemise pemineS, no City elected official or employee shall have a l^a^ctatMteiiBtMfiis or her own name or in the name of any other person or entity in thepurchase ofany^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"). COmpensatibn for property taken pursuant to the Citjrts eminent domain poWet does not Constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property
[JYes []No
3. If you checked "Yes" to Item D.l, provide the names a dfiiciaisdf employeM^
Name Business Address Nature of Interest
4 The Disclosing Partyiurihetdiel^fie^/aia't no prohibited financial interest ih the Matter will be a^uifed by any City official or employee,
'%. ^i^f ICAf ION RH(^RDiN©iSLAVERY ERA BUSINESS
Please-check either 1. or % .be1b.W* ;ff|K|:0iselpsing Party checks 2:, the Disclosing Party must disclose bekw or in an attachments required by^ pM^fapfi 2C Failure to
cbrhply with these disclosure requirements may make any contract entered into with the City in conheetioh With the''Hat%'Voiia^l^py'^e''C3ty
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 investrnents or profits: /from slavery or slaveholder insurance policies during the slavery era (including insurance policies is>ued: tp siavehQlders that provided coverage for damage to or injury or death of their slaves)* arid theDiselosing Party-has found no s^ch records.
2. The Disclosing PartyVerified that,as a result of^^conducting the ieafch in step 1 above, the '-D:iieJ6;^|( Phrtyhas found records pf investments or profits from slavery Orslaveholder in&Uranee policies. The Disclosing Party yerifiesihat me following constitutes full disclosure of all such records,/including the names of any and all slaves of Slaveholders described m those records:
Page 8 of 13
SIIGTION VICERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: Ifth^a^r.M«4eraI% funded, complete this Section VI. If the Matter is hot federally funded, proved to Sectiptt VlL For purposes of this Section VI, tax'ci«dit8^11b'cated:by''^,dity arid proceeds Of debt obn^
A. CBRTD7ICAT10N REGARDING LOBBYING
1 ., List below the names of all persons or entities registered under the federal Lobbyihg Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheetsifnecessary):
(If ho explanationappears or begins On the lines above, or ifthe letters "NA* orlf theword "None" appear, it Will be conclusively* presumed that the Disclbsing Party means that NO p^efsbns pf entities registered under the Lobbying Diselbsure Act Of 1995 have made lobbying contacts oh behalf of the Disclosing Patty with respect to the M atter.)
2. The Disclosing Party has not spent and will not expend any federally appt^pri^d'^ds-tdpay. ahy person or entity listed in Paragraph A. 1, above for his or her lobbying activities br to pay any person or entity tb influence to influence an officer or employee of any agency, as defined by applicable federal law, a member Of Congress, an of ficer or employee bfCongress, br anvehlplbyee pf a member of Congress, in connection with the award of any federally funded contract, makihg any federally funded grant or lbah, &ti{0tig uito any cooperative agreement, or to extend, continue, renew, amend, or modifyMyf^ loan, of ebbpefatiye^.agreement.
3. The DisclOSMg Party Witisubrhiian updated certification atthe end of each calendar quarter in which there occurs any.event that materially affects the accuracy of the statementS and infprmation set forth in paragraphs A.l. and A.2. above.
4. 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".
5. Ifthe Disclosing Party is the Applicant, the Disclosing Partymustobtain 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 ofthe Matter and must make such certifications promptly available to the City upon request
Page 9 of 13
B. CEKf IFiC AT ION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
Ir;ffi>M8^ri$f$d^}l^ funded, federal reguUitionstequire the Applicant arid all proposed subeonttaetors to submit the following information with their bids or in writing at the outset of negotiations,
Is the Disclosing Party the Applicant?
[ ] Yes [ J No
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?(Sbe 41 CFR Part 60-2.) []Yes [JNo
2. H^ve you ftled WJ
Cpntract Coinpliance Programs, or the Equal Employment©ppoftuhity Commission all reports due ufli^e| ^eappile|ble fifing requirements? [JYes [JNo
3'.; Have ypu participated in any previous contracts or subcontract subjeet to the equ^libppof tuftijty clause?
ti^es ' V. .[JNo:. "
If you ch|cge;d "No" to question 1. or 2. aboy
SFjCTTGN VB -r ACkNOWLEDGMENTS, CONTRACT INCORPORATION, C0MPLMN0E, PENALTIES, DISCLOSURE
The biselbsihg Party understands and agrees that:
A. The^ cbrtificatiOns, disclosures, and acknowledgments contained in this EDS Will become pait of any contract pf other agreement between ihe Applicant and the City in connection with the Matter, whether proenrement, City assistance, or other City action, and a^^tef^tMdJcfetfeii^ to th^Ci^e^eciaJ^ of any Cphh^cf or tajdng other action with respect to the Matter. The iisclosihg Party understand^ that it must-comply wr^
B. 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 linc at wwW.citvofchicago.orB/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.
Page 10 of 13
.-S^^wScd^St.-?-SuitevSOO«.'<^ki'cB^Bxo§ U* 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
C. If the City deleMihes':tbataJny ihfd^£Udh''pf6yiiifibd. in this EDS is false,.k4pm^i@jM,prwaccurate,, any contact-or other agreement inconnection 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 ^tiiry, ifieluding^^i^^at&sJt^e ^'IsckisitijE -Far^i ^^c|{f8tibn<ln:the-M'atiEer anc!/or declining to allow the Disclosing Pafty to participate in other transactions With the City. Remedies at law for a false statement of materialfact may include incarceration and an award to the City of treble damages.
D; It is the City's policy to make this document''available to^ die pubtic ph its Internet site and/or upon iequest. Some Or allbfthe 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 Patty WaiVMIMd^kases any possible rights or claims which it may have against theGity in connection with the public release of information contained in this EDS and alsb authoriizes me City tb verify the accuracy of any irifomiiatibn submitted in this EDS.
E. The informatibn provided in this EDS^must heikepf current Inlhe event of changes, the Disclosing Party must supplement this fibs up to the time the City takes action bn the Matter. Ifthe Matter is a contract being handled by the Ctty*s Department of Procurement Services; theDisclosingParty must update this EDS as the contract requires, ftGTE; With respect to. Matters subject to Article I of Chapter 1>23 of the Municipal Code (bhfb^ certain specified: offenses), the information provided hefem regarding eligibility must be kep cufrenffot a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.,
The Disclosing Party represents and waftahts that:
F. 1. The Disclosing Party is not d^inqueht ih the payment of any tax adntinis^djb^^e^^mois Department Of Revenue, hor are the Disblbsing Party or its Affiliated Entities del&il^lit^^^aity fine, fee, tax or other charge owed to the Cily. This includes, but is not limited'M^0^0it0--iM^^r seWcr charges, license fees, parking tickets, property taxes or sales taxes.
F;2 If the Disclosing Party is the Applicant, the Disciosing Party and its Affiliated Entities Wlllhbt use, nor permit melf subcontiactoi^ to use, any facility listed by the U.S. E.P.A;^in^e^b^ral Paces' List System ("EPLS^ maintained by di^ u. S. General Services Adi^btnili^'
F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcbntractbrs hired or to be hired in connection with the Matter certifications equal in form and substance to those in P. 1. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason tb believe has hot provided or cannot provide truthful certifications.
Page 11 of 13
worn if the .
explanatory stfte^m^:^^ fe thi* BDS. * * °'Mi *** «*
CEKTIFlCAfiON
I to execute
and c.ntpicle^ bf &2SS3SSSt^^*Aj^* <«"**«*
-ginoj-jfe g^^^i ^rr-rnr<nn
(Sfgnherc) ~2?2lMj|' Kerr
or type name of person signing) ^^SS^SSSS^ * ^?isbant CSt^ra^ ^cretary
I^^Sw^w' b^imo do (data} Jk4 .ifogftfo ,
^Notary Piibiic
Pngc J 2 of 13
CITY OF CHICAGO ECONOMIC DiSCLOSUit^S^Eil^r^ AND AFFDDAYIT
APPENDIX A
FAMILIAL RELATIONSHIPSWITH ELECTED CITY OFHCiALS AND DEPARTMENT HEADS
TluY Appendix is to be completed only by (a) the Applicant, and (b) anylegarentity which has a direct ownership interest in the Applicant exceeding 7.5 percent If is not to be completed by any legal entity Whichhas onlyan indirect ownership Interest in the Applkant.
Under Municipal Cctf^
or/anylAppifcabVfc^ a ^fa^iaal^^kdi^t^^ll^'
any elected city official or department he^d. A "familial relationship" exists if, asofthedatethisEDSis
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderhiarii the city clerk, the city treasulrer or ahy city dep^
partner or as any ofthe following, whetherby blood or ador^
niece or nephew,grandparentj grandchild, fether-ihrlaW, mother-m«lawf s6h-m^
or stepmother, stepson or ^epdaughter, stepbrother or stepsister or half broweror hai^ster^
"Applicable Party" means (1) all executive officers of theDj^ipsing Party listed in Section h*.B,l ta., ifthe Disclosing Party is a corporation; all partners of the jT^iosdhg^at^, if the DkclOsing Party is a general partoerfihlp; alligeneral partners and limited partner^ bf the Discl^ lhnlted partnership; ail managers, managing members and members; of the I^SciosmglPar^ if the Disclosing Party is a limited Ha&b"tycompany^(2) all principal officers of th^ than ai%5 percent ov^ership interest mtM Disclosing Party. "Principal officers" means the president, chief ppei£^ chieffinancial officer,^^;trelisUrsr or secretary of a legajlehtity of any person
exercising sinuTar authority.
Does the Disclosing Party of any "ApplicablePaf^y;, Of anySpousecor Domestic Partner mef^fciir|etttp have a "fafMlial relationship" With an elected
t ]YeS " [£No " . '
If yes, please identify below (l)the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name andjtitle ofthe elected city official or department head>ip whom such; person has a famih'd relationship, and (4) m
Page 13 Of 13
MANU1 j FE FINAjVCI AL CORPORATION DIRECTOR AND OFFICER LISTING AS OF JULY 25,2011
DIRECTORS
Gail Carol Annabel Cook-Bennett |
Chair ofthe Board |
Donald Arthur Guloien |
Director |
Linda Beth Bammann |
Director |
Joseph Peter Caron |
Director ' |
John Michael Cassaday |
Director |
Thorhas Paul d'Aquino |
Director |
Richard BernardDeWolfe |
Director |
Robert Emmeit Dineen, Jr. |
Director |
Scott McKce Hand |
Director |
Robert James Harding , |
Director . ', |
Luther Sherman Helms |
Director |
Donald Richard Lindsay |
Director |
Lo ma Ruth Marsden |
Director |
John Ralph Vemon Palmer |
Director |
Hugh Walter Sloan, Jr. 1 |
Director |
Officers-
Donald; A. ;Guloien |
President and Chief Executive Officer :: - ■.'-: |
Michael W. Bell |
Senior Executive Vice Prcsidcnfand'Chtef Financial Officer ; : |
Jean-Paul (J-Pi) Bisnaire }, |
Senior Executive Vice President, Corporate Development and General Counsel |
James R. Boyle |
Senior Executive Vice President, U.S. Division ;.-3. |
Robert A. Cook |
'Senior; Executive Vice President and;General Manager;; Asia |
Paul L. Rooney |
Senior Executi ve Vice President and General Manager, Canada |
Warren A. Thomson |
Senior Executive Vice President and Chief Investment Officer |
Cindy L. Forbes |
Executive Vice President and Chief Actuary |
Scott S. Hartz |
Executive Vice President, General Account Iftvestmente |
Stephani E. Kirigsmill |
Executive Vice President, Human Resources- r |
Beverly S. Margolian |
Executive Vice President and Chief Risk Officer |
SUPPLEMENT
TO CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT
To: City of Chicago DOE/CDOT
Matter: Extension of City Use Agreement (Amendment #26)
This letter is being sent by Manulife Financial Corporation ("MFC") as a supplement to its Economic Disclosure Statement in connection with the above-referenced Matter. MFC is the ultimate beneficial owner of John Hancock Life Insurance Company (U.S.A.), successor by merger to John Hancock Life Insurance Company ("JHUSA"), a legal entity that has an equity interest in the indirect parent of MDE Thermal Technologies. Inc. (the Applicant).
MFC hereby confirms that the following subsidiary of MFC comprises all ofthe director, indirect parent entities of JHUSA (which entity is directly or indirectly wholly-owned by MFC), and the full name and title of all executive officers and directors of said entity are:
I JOHN HANCOCK HOLDINGS (DELAWARE) LLC (a Delaware limited Liability Company)
DIRECTORS Brian Collins William Langan Lynne Patterson Amy Stengel Jeffrey Whitehead
OFFICERS
Lynne Patterson, President
Brian Collins, Vice President
William Langan, Vice President
Steven Moore, Vice President and Treasurer
Kris Ramdial, Vice President Treasury
Jeffrey Whitehead, Vice President and CFO
Heather Hill, Secretary
MFC further confirms that the certifications made by MFC in Sections HI and V of its Economic Disclosure Statement apply also to the entity listed above.
Very truly yours,
Name: David R. Kerr Title: AVP, Senior Counsel & Assistant Corporate Secretary
Page 1 of2
Monica or Bryce, can you please give me a call when you have a second? Thanks.
Adam J. Penkhus Daley and George, Ltd. 20 S. Clark, Suite 400 Chicago, IL 60603 Phone: (312) 726-8797
Fax:(312) 726-8819 " ^
Adam, it was nice to make your acquaintance last night. Attached are the EDS forms that were filed in connection with the purchase by John Hancock ofthe interest in MDE Thermal Technologies. At that time, the intermediate holding companies were not required to file an EDS although I note a supplement was filed by John Hancock Holdings.
On December 31, 2009, various subsidiaries under the US operations of MFC reorganized. The net effect of the reorganization was John Hancock Life Insurance Company became John Hancock Life Insurance Company (U.S.A.) and an intermediate holding company was dissolved making the ownership structure between MFC and JHUSA a bit less complicated., (These facts were disclosed to the City at the time John Hancock bought its interest from Macquarie.) Aside from the supplement, an EDS was not required for the intermediate holding
companies. Certain additional facts may be helpful in your discussions.________
___ PsimTlar to the
state of facts in 2009 when the last filing was made in connection with this company. Thus what I tried to do was replicate the filings made in connection with the acquisition in 2009.
Another data point may also be helpful. John Hancock Life Insurance.Company was part of a consortium that was the successful bidder for the purchase of Midway Airport. Although for various reasons the purchase and sale did not go through, I believe EDS forms were filed consistent with the approach taken above.
I am available to discuss this further with you at your convenience.
Jack
John T. Wallace, Esq.
AVP & Senior Counsel, Investment Law
John Hancock Financial Services, Inc.
John Hancock Place
197 Clarendon Street C-3
Boston, MA 02116
Tel: 617-572-9245
Cell: 617-784-9300
Dir. Fax: 617-421-4036
Gen. Fax:617-572-9269
STATEMENT OF CONFIDENTIALITY
The information contained in this email message and any attachments to this message is confidential and may be privileged or constitute attorney work product. If you are not an intended recipient, please (i) notify me immediately by replying to this message, (ii) do not use, disseminate, distribute or reproduce any part of the message or any attachment, and (iii) destroy all copies of this message and any attachments.
AND" AFFIDAVIT
AV Legainame of the Diaebsiiig H^mj^Mi^Mimtit Include Mt&l tftpptiesMfa
Cheek ONE ofthe
ihfes boxes:
Ihdicate whether lbs Disclosing PafJy submhting Ihia EDS is: 1. 11 the Applicant
m
2< M a legal entity holding a kmwi^^tmstm in tbe Applicant. Itateiihe kgal rjame rbfthe Applicant in whteh $e Ijiaclasittgfa^^
:Of. ' '' "MB!^M^'"T. r v f
^I^iliy ^M Siate^ legal flaaiS ^
fit* Business;
i ofthe
C> Peptone: .,^V^l,.Lm__ Fax::, Afr^frfr - a Et»^ Jb*^_^^
Si Federal Employer Identiflearioti Noi(if yod have one):j
MWefffe^fffldii of sontrad, traflsaciibn pf btitef undertaking (referred to below as the ftMa«ef");to 1 this EDS peftains. -'(melttdefIb^-tWfflblti:- and location of properly, if applicable):
O. Whish City agency or
If the Matter is a cbntractpeihg hahd1ed% ebmpletethi following?
tent of Procurement Sefvicesi please
Specification it
and Contract #
Pag® 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THB 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))?
J Limited partnership [ ] Yes [ ] No
] Trust [ ] Other (please specify)
2. For legai entities, the state (or foreign country) of incorporation or organization, if applicable:
\Nt_vo,^orc_._
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 j^No IJN/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 titlehoider(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
-:__'VfrV.XiWVt-^a-: K«-j^-.
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
fe<^8t'd£fl; M&WM-tifWtagei in a limif«a lia^U^ benefleiary^f a,tfo«t,;
8S^o*h|^islp||fpth>v EnhOf^te
|pn|feh^i^jf'#^ jp$fcrii^ any susfe^
WON.jBI ~ BjJ_j:iw;_.S'MLATI0NSH_Ki WimCtTY E'LlCTfiD-O'Ff 1CL4L-
Has the Disclosing Party Bad a %usifiess■ii^ftdfaiiSirp^w.delitted in Chapter 24 36 of ihe Municipal Godi, With ahy Oity elected official in the 12 months before we date mis EDS Is signed?
Yes j^Ne ^^^t^^^ni^:Mm. tfo ha'rh^s)':df mvk&ity&p&ft «fScia1^ahd describe such
:$XCitOH IV. * DISGLOSUSl® OF-SIJSGONTRACT0M ^tt&'ilff^M^A^M MMtlM
The Disfilo-ing Party must diselbse the name and business address of each ^ubcohttactor, attorney, lobbyist, accountant* consultant and any other person or entity whom the Disclosing Party has retained ;tff#jp*Ctt #^lfl.lti.^tEQ«<$tio-'wifli the Mattef, as well as the natui-s of the relationship, arid the total allhouni df the;;feeSpaid^pf«stintatSd% be paid, Th® riiSGldgiflg Pafty is hot required to disclose employees who are paid solely through the Disclosing Party's regular payroll,
ll^l^-t^-^^nmei^iifko undertakes to iflfluehcs ahy ligirfafive or adlnkistraUye action on behalf^bif any pefson or entity other than: (i) a nut=fe unpaid bsslSi or (2)
himselfi "Lobbyist" also means any person or entityany part of wbp§e doties as an employee of sifijol_.cs! ihclud^.«hdeii^ih.g:'fd mfluehce any iegislahVeof i
; Party is uhcertalh whetfeel a s
Dis^aiil|S^^
diselbsiiri' is
undertthl? Section, thf m tfi'^M^diseiami'^
Page $ 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
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 ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Ves , No raNo person directly or indirectiy owns 10% or more of the
Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
(JYes fJNo
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article l")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), ifthe 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 thai compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
2. ap^if tniDisclbslnjgParty; te5a jigfal eatl^« at j 4ttMi&$0$&orm$Qa
& :l^;nb^||^^^
' obtamjng, alfemptkg;io <)bfaiiii drp (^rai^stft^ or ioca^^fl-actida or
eohlriei ui)4§r ajpubiie fraasacnbii; a vloiatiotf ofl^^w^^^^im- Wtto^rfraud; etafeezzlefflent; tneft; forgery bribsry^fo ordeStrttetion of records; making false
statements; or receiving stolen property;
cv. arenot^
state or loeai) witb comMttlag ariy of ffie:ft1<^'w8''Mitfd#:.in clamse B.2.b. of this lection "V^
d. havradtv ^ifbin a ^V^yi^>p^bd^^e'oIfl^ttic date of this EDS, had One or indre p-biic frittsactidtis |fedef al, state or local) j^ptiw^foi!- cause or default; and
e. <hM&op$ «tf&hi&a;f^^ BDSvieeri- cohvi^^ g«illy,iOf found ttebie it 'a- «M':iMe^ja^^-iia ah> -etiiiuna- of civil action, including actions conej^ by the City Or by the federal gOveMmerit, any state; orany other unit of local |We&M6_.
3j, Thle^grK^
« me Disclosing Party;.
fatty- "Coafacto^^peaantgady fohfrac1o#;o^ by &&'-®IMvaiftg%iffl in
cbifaeietlM
any '- Affiliated Softit^** (m^ahhlg a person df ki^ ^i ^milfy or indh4etly: contfois the. Difi^lpiihg PaHy^ is eo^^^
6&W&m%6W6l of ahofhlr person or entity. Indicia of control include, withbut limitationi mtefieekifig^ identity ^
and e^ulpfflehtiieomnioh use of employies^pt'' 6rglinizflti6ii of a business entity following the ineliglbil^
the City, using substantially the kme mah^ as the ineligible entity);
with respect to Contractors, the terni Affiliated Entity means a person or entity that directly or ihdirestly coatrols the Contractor, is confiroilsd by it, of, wim the Contractorvlsunder common control of another person or eflfify;
♦ any responsible offeal of the Disclosing Party, anyCouttastof or any Affiliated Entity or any other agent of .mployee of the^isdiiMn^PMty, |hy :CdBtfaetor or any AfflllatVd Ehtity,
C^nh^ctor orany Affiliated
mi 13
tMfjany^jg^
bribed of aite^ of beeh^fly^ or attgmpting to
bribe, a public officer Of gfflpteyeeo_^
govefflihebi or Of any ateie or lo:ea%ovgrameflt iti ihe tlnlfea SMefl of Arhef ie&; ihtbl* ofleer'a Of employee's offlsfal capaeftyl
1 bf edluded with othef biddefs or pfospe^e bidders, of betn a pafty to ahy such ii df been cdnvkied oradjudged; guilty of^^agiierfleht or collusion among bidder* oi ivebidders, in fettrakrt of fkedomtdf co^ ipMi-4-Medpti^ pt
c» made ah admissidn of such conduct describedih a. of b» have not been prosemited for such eojffdue%:pf
i that is a matter of fecbfdi but
d, violated the provisions of Munielpai:^ Wage
■4,
W^irrthe^iiEipsIngParty, A^lktidif|ti^or ofBdafs, agents- of'§&t^&<i$iS!$M from contracting wltfcia^ of . e^aghig^ffl\bf5being eerivlsteci of (1) bldif igglhg in ^6^i^^Wlf^i^/iii4i (2} &rbtatlh£ in yioiatiofl of litifLCS J/33E4j or (3) ■Mii^iiia^'d&^i^MfM^ or of the UBitedtates of America that contains the same elements asthe offense nf bfd^figgiitig or bid-rotating.
B. Nfith^f the^ fflainMhed by the Office of Foreign Asse^
Bureau of Industry and Security of the U.S. Department ol eommef ee or theif successpfsi the Specially peBitflated Nationals List, the Denied Persons List, the Uftvetiffed'4M, the Entity List and the
6, ; The DiSiibgihg Party understands arid shall ebmpty with me^ppikable requirements; 24$ (ieglsiativ^ Municipal Cbd^.
7. If tfie Diseipsing Party is unabi^to eeitify feany ■df ^mbWM^Msmsnis'in this Paff Bi (Further Caseations)* blsciosiag Party ihus'f.e*pjph> bf tew;
Pagi6 of 13
If the'Ma$$fk,\ the vyor'ii" Wm r%spdnsg appears en thr jiffiis above, 1 will be. cooetoiiveiy ftfeMmGd^
1. The eisclbsing P&^ymMfi^&iSm the Disclosing Party (cbetk one): {jiff ^fiSndi «>^^pie^^b*W#tti, a* def^
1 If le Disclbsing Jar^ IS aflaflsial faie^Miidi|rSii^^d:Dls«l«>'8Stti' Party pledges:
arenpiadd will net beebme a predatory iebderaideffeed in ChapiMf42 of th® Municipal Code. We further pledge that noneof bar affiliates is, and nbhe of them will become, a predatory lender as definedtn Chapter 242 of the Municipal Cede. We Mndefstand that^^^becomingja predatory leiidetpr beeohiing ah affiliate of a predatory lender rtay result hi the loss ofthe privilege of doing business with thf City."
If the DisclosingParty is u%eie; to ma^^ defined ih
Section 142MB(b> of me M^hieipal Code) is a predatory tgflder wimih tk meaning of Chapter 242 of iie Municipal Code, explain here (attach additional pages if necessary):
If the 1$^^^ 'tfce lmea;abov§, it will b©
cOnelu^^yprefiumf^th^ the Dftfelb>|^^^
D. CMfc#T:i^
My wordsvor terms s«me meafllhis when used ih this Part 0.
1. In accordance wltb; Section 2«1 frl W-oS m MtmiCipal Cede: Does any official or employee of m« City Mve a financial interest in his or her own name orlh tlii name of any dine* person or entity in me Matter? /
£3 Yes M.Ne
NOTE: If ye« shejgk^d HYeS" to Item £); 1 *, proceed tb;Item£0.2, and D.3, I%eu checked W to ItemD.l.*^
1
eiaj^'em^^^sh^i h^ea fihan$^ 6Wsigni£p:^
for «^;oi,'"t^i!«8^§i^i, ©f (Hi) is sold b>^ City Ceoiifeetiveiyi
**c;iiy Pi"i»j>4ny Saie*'). Compensation^ eminent domain power
dd«s floi ebnstiuik a fm&nsiaf interest within themeaning of this PaffDi
Does the Matter involve a City Property Sale? [JYes UNO
3. If you ehecked "Yes* to Item D.l., piravide th« aames aad buaiaesa addressesof the City Or employeeshaving such rhatercaft'aad^ijdigitll^ Ule^i1i^*air«v'oi^^^l1^tf infsifcsii
lame
Business
i.0flfltefe;8f
4. The
Party furmeficertifles tfaafno any City .offieiai or *
■fmanftial infsfest in the Matter:^ill
B. CBRTtFlCAf lON REBARDINd StAYERY ERA BUSINESS;
Please cheek either 1. or 2. below. Ifthe Disclosing Party checks 2., ihe Disclosing Party must disclose below of in an attachment to this BDS all information rebukedby paragraph 2. Failure to . corhi>ly with thes§ disclosure requirements may make any^ cohtfaet ehtefed into with the City In connection with the Mittef voidable by th® City.
hg Paiiy verifies that the Disciosing Pafty fi^s seafched any and all fecprds Of the Diselosing Pafty arid any and all predecessor 'entitle ^^^^t^0M:ofW^^^^t profits from slavery or siavgholdef insten'Sf ■poiieif i durtflgtheilav^p efa^ifletufl^ issued to slaveholders that provided coverage for damag&to or I -the #is$iib*{n^
- -. .-.;2t. Tfa^plsctesing^^
Disde^ing Parjyha> reeor^of invsg^^ $l0i$U^%$&wm® policies. The DfeloSih| Party verifies that the ibilewhig^ebnstittttet fiiSl disetbsureT©f rail-such; b, iheludifig the names of any and all slaves or.slaveholdersdescribed in those records:
section n ^&RT3ncATroN£t^
aMp^#^of%i»^
a. %M%timm&®kEOAfcDrNG lobbying
1. L3stbelc& m@ hamts of all per9^:of;\ettnti«f.i|^8t«^! under uie federal Lobbying DraeidiUfe AcTof 1995 who have made lobbyihg eoataets oh behalf bf theDiaelosing Party with r$sjj«ejt to the.Matter: (Add sheets if necessary):
(jtfhoespja^^ lines abeyeiorlftfte letters "NA" of if the word "None"
#pgajfii^ tlat NO persohs of entities^
'fefis|j^itit^#%« Lobbying Disclosafe Act of 1995 have mad® lobbying contacts m behaif of the Disclosing^ Pajpty with respect to the Matter.)
2. the Disslof ing Party has not spent and will not Mpettd any federally appropriated funds to pay atiy pefSol Of eluiy listed ia Paragraph A, 1. aiovi fof ito or to pay any
per son orentity to influeriise of attempt to irifluenee an officer or employee of any agency, as defb§d by a^plicablg federal law, a member of Coflgtpay an ©ffi{5#of employei of Congress* or att eniploye© of a member of Cd^
federally fuhdedgrant or loan, entering into any cooperative ag^ continue, renew,
am^bd, or mbdify any federally funded cpntract,,gf aht, loan, or cooperative agreement.
'■ 3.
ie Bigeibsing Party will submitan updated ggrtifieatidh at tteend of each calehdflf quarter in !t^oecttf& any ev*nt mat materially affects ihe ae^^y'ol^ala^inib'tS'iittd ihfbrmatioh sft foifth ihipafa^phs '1
4 :^^#sing:parf ■Aetivitis#;- ■
tCedVbf ;]^^ section
I; if theBisclbling Party is the Applicant,, the ^ie^D^P^tiiiiifst obtain certifications equal in form and substance to paragraphs A.l. tbtbughA A. above i^bni all aubeonfraetors before It aw ards any subcontract and the Disclosing Party must mainWrt jail s#h sutttbiltf^j^rs^ eertifieatioiis for the dufatlbn of the Mltter and must make Uttdlr c^f^catlbii^plr^^tly available to the City upon request;
Pagg 9^ 13
^Matte is afrpL,___
Is the Disclosing Party the Applicant?
UYes; i,]Nd If "Yea? answer thetl&ee q^ilpus h«
pand:db.'
1. Have you
regulation*? HTss
i.$aMuaht to^jpfafelg
4 Mave yelled ^img^ iihderme applicable filing requirements?
#qb|Jibpfo^MfyJelaviai'l ' ■, '■ .■- - ' ,,; .
iBfe / T.c:,,U=/ni&. ■ . .... ^-i:
SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES^ DISCLOSURE
The Disclosing Party understands and sgtges thab
fA. The certifications, disclosures, and acknow.Iedgacflts mMmd in Ws EDS will bnoaupm of any contract or other agreement between the Applicant and the City in eottteettai with the Matter, whether procurement, City assistance, or other City action, aad are material inducements to the City's execution
117?!!*? m iaki^ ottKf act,oa wl<h t0 the Matter. The Disclosing Party understands that it mm comply with all statutes, ordinances, and regulations on which this EDS Is based.
8. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters US6 and 2-154 of the Municipal Code, impose certain duties and obligations oa persons or entities seeking City-contracts, work, business, or transactions. The full text of these ordinances and a training program is available on at ^.^■c'tyoffiluc^o.or^/Bjthjci, and may also be obtained from the City's Board of Ethics, 740 N.
Page 10 of 13
tttMt comply fully
mayfe r^iadidor be*oid*r ^^TtS|,1tr ^f;^ ^^ ^.fe pablk on Itt Ihiefnet site and/er upon
as ^ufred by Chapter ,1^3 iftd^ or a lonpr f enod,
ari^wafrant^bat
n J?** 52 8 *<S 1104 dellB4««rt in the payment of any ^administered by the Illinois Department of Revenue, nor ara the Disclosing Party of ife Affiliated Entities delinquent in paying any
sewer charges, license fees, parking tickets, property taxes dr sales torn,
!f «il^lui!?tSifllPar?1& ihe APplkflnt'the ^^ih8 Party and its Affiliated Entities will not Parties List System <»gPLS«) maintain^ by the U. Crenel Sdtkw Administration,
P.3 Ifthe Disclosing Party is the Applicant, the DiscloslngParty will obtain from any ZnT/!TlTTT hifSt0r 40 be hkc6 in toaae°an with ^Matter certifications equal in r5? "l^T °f . ^ and V2' *bove m6 *?m m> *ithout th« Prior written consent ofthe C ty. us* any mh contractor/subcontractor that does not provide such certifications ot that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
Page 11 of 13
NOTE: If the Disclosing Party cannot certify as to any ofthe 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 lo execute this EDS and Appendix A (if applicable) on behaif 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 ofthe date furnished to the City.
/^foffltiffg DtfraiT 6A/e&w
(Print or type name of Disclosing Party)
By:
(Sign here)
(Print or type name of person signing)
(Print ortype title of person signing)'"' J
Signed and sworn to before me on (date) ZSolw I at AJY _County, MY (stkte).
tihupjj ft O^rr'^ , Notary Public. Commission expires: 11 I j 14_.
H-'.).Ty nwuc-zr,\\c <-.t new \ ■ "k
"lu.^lllc-! In New Yoik County
Page 12 of 13
: is to be-: eomplet fid only by (a) the Applleant, «■£ Ch) ait? legal eiiflty wbteh has a Sired Mui «i«0ediiig ?iS pereejjfc ItliThoWbe' eflmpleied by mf legal entity -Wfiiek:to& onfy ah bidtri$t ownership interest ktte.A4^pf|iei|iib
tJ^Mu^ipdta^ Sechdfl2*lf4^015s ih® Dlselb^'pi^^i^'Mds^' whether each DisclosingParty bre^^%pl^»viy^vpfahy Spouseor Dotnesfie Partner tlieretrf^ with ahy elfefed ctt^pffidal or department heed. A "faraiiial relatioflship" exists % as pf the date this IDS is ?igtte^die Disctosihfe
^:^^^,0$W^^ui> the city clerk, the:eity trgM^ head # spouse: or domestic
WMlawkg,; wheth^ byblopd oral^bhrlif^
iprflgph^^
'mea»(l)y&ll mmtirite S^ljS^^Eii^. ti^t«)d^ .B#$tcei t£8.1.-&117i<h'e:
tftyis^ #a&j^ pa^e^hi^
flrnlied ^ aiipriflcipai officers -of'the pi&ld^ more tiiati
■x^iS;;p^^[p0^l^-Met!&i hi the Disclosing Party. "Pfutsipai b^^'.fiie^M president chief op^ting dffleer, e^elutj^e dii^for, chief financial officer, ttm\im<bt:i^tafy:of!& legal en% Of toy p"eiton
Db^ the^ls^sln^Psrty orany u,
'of anySpouss ofDofliesle Partner thereof curfsntiy otdepaitentb^ad?
statement
■SmCTlOHT.
a, Lepihame oi tp
INFORMATION
1. [ J -Ui* Applicant
this EM la;
2i a legal entity holding a direct or Indirect interest in the Applicant. State the legal name ofthe Applicant in which the Disclosing Party holds an interest: "f^^/Zd^^/^/ OR
3, (J a legal eB%.-wMi.rrlght of control (see 8ec«lon 11.B;1.) State the legal name of the entity ifi which the Diseioaifig Party hoids a right of control: .... ... . , ,........... _________
B. Huaihess:
iofthe:
t)V WBSiiSfW^ person:1 rV%*j^ ^ttem
B. Federal Employer Idehtification No. (if yoi have one)
P. Brief description of contract, transaction of other sindeftaking (referred td below as the "Mattef";; to which this MbS pertains, (include pfojiet nantbef &M loeation of ptoperty, if applicable):
O. whieh City agency or department
If the Matter is a contrast i complete the following;
Specification # ______
i handled by the City's Department of Procurement Service's,.,;
and Contractfr ^,______
A. NATURE OF TM&fi#&©im*3 M#
L
XI Person
j^Privkelyhgjd f ]; Sols pti { ] General t j Limited I J Trust
coiipofatiGh i ebfpdraltion
t ] Limited liability edmpahy
[] LimitedliabuitypaMershtjj
[ 3 3©li» venture
[ ] Not-for-profit eoipoBticfr
(Usthe Ufri'i&t'pwtiicorporation also i
tlYee 11 No
13 Other (please .speei;
2. For legal entities, the State (of foreign country)of incorporation Otargahfealbh, if #piteable:
; rsglstgf«d to do
3. For i#gaf entities: not ofgahi^ld: in the^biite^iJBatttffi ttea the fit business m^
UYe» ^No t]N/A
B. IF ta&filSCLOSlNO FARTY iaA L
1. Listbelbw the full names and titles Ofail; executive officers and all dife^tors of the entity. NOTli For tfot-for*p1N^ also list below ailmembers, if any, which are legal entitles; If
'there ate no m^<i^^^^'wmi'i!^^^*' Fortwsts, estatesof Otfi^ the legal titiehiidef(s).
If weMtity isag^ paftnefship ofjoint vehtufe, list belowrihe: name and htte of ^ managef offlhy omer pe^
NOt'i: Eaeh legal ehu% listed belbw mast submit an SOS on its own behalf.
Title
2. Please proving ia indirect beneileiai ihtefest of such an interest include
inforfliatloii eoneeming each person of ownership) in ejteeffs of 1.5% ofthe in a corporation, partnership interest in a
:;or
Party. Examples or joint venture,
Page 2 of 13
-e|^d^'o^ ftb)iiiBr'e_%- tf'iteii^Jlite;4^^ Mi'ft:PursuantM Section 2414*030 of the Muai^ tii^lty ttay rggulfg any. sueh addlnttal mfbrraation
fror^aay applicant whte^ reasonably mtefldeo id achieve tau dbeipsure,
baffle Business Address* Percentage Interest in the
wait&®tmwm£TmB wnciAhn
Hasthe Code, with any i
11 Yea
Party had a ,,hnsine88:relatioh8hip,,, as defined in Chapter 2456 of the eleefed offleiai in the 12 months before the date this EOS is signed?
too
below the tiame(9) of stieh City elected officiai(s) and desefibe sttch
section iv -mmhomm■m&t&cawrBrnmm^ awothsk metaiMib. vAmnm
The Olielqsing Party must disclose the hame andbufsihefls address of eaeh subcontraete, attorney, lobbyist* aeeotatant, gohsultaht and any omer person of entity whdrn the Disclosing Party has retained of eapeets to refalh in eoflheetioh with ^
amouht of the fees pgM or estimated to hi -paid; The Diseiosing Party is not reqttif ed tb disclose employees who.-jarspaid solely thfough the dlseibslblParty's fegutaf payrolL
Ibbbyist" hieaos any person ot entity -^^oiMkiamiiid^!^ any legislative of adtnMsirative action onbtlialf of any person of enti%owef mahl: (1) £ riot^or-profit entity, on an unpaid basis, or (2) himself. ^Lobbyisf also means any person of entity any part of whose duties as an employee of another includes tmdeftakiflg to ihflueh^eahy legislative or administfatlve aetibn.
Ifthe Disclosing Party is uhceftaln whether a disciosufe is required under this Section, the Disclosing Party must either ask the City whether diseiasttrs is required or make the disclosure.
Page^bf 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 respoosc.
(Add sheets if necessary)
f^Check here if the Disciosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person 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?
1J Yes No m No person directly or indirectly owns 10% or more of the
' Disciosing 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?
UYes []No
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), ifthe Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency, and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: [f 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 DiseJoitag Party and* ifwe-IUMl6t^g^ai^ii:«-feg«r:iati^ allbf'these pefg^sbf §htitiel letrtifiej ittlMioatl&Ar6f%m%B$:
a, mm^m^4^m&ii suspended, ptbpbggd for debatineot, declared ineligible or vdluntarily feMIttded from ahy baasactibris by any federal, state or leeal unit bf government;
b> have not, Within a five-year period pmedkg^ ^at^iMs Mi^ hm convicted of a criminal Offense, adjadged guilty, W .obtaining^
'contract under a public transaetibn; a violation of federal or state antitrust s tatutes; fraud? embezzlement; thefts forgery; bribery; falsifieaiiofi ordestruction of records; making false statemehts] of recipivlttg -^stolen property;?
& are no^resenil^ charg^'S^a;^
stfe or local) with-committfag an^-of threfi^ of this Jetton V?
d. havenpi, wiihta a £ve*ye^^ EDS; bad one of mere public
transactions (federal, state or local) tefminated for cause bf default; aiid
■*. have net, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil pfoeeedlng, or in any efiminat of civil action, indudihg actions eofiegfninge^ ihbMlt^-b^-thi^^df;b> the fedefal government, any
state* bf anyOtherunit of Ibeai jovefhment.
3. The ceftlficatibns in subparts 3,4 and 3 concern; the DiWlosmg Party;
* any ''CbflfrM^ bfrW$fM*ifflg Parry ih eonheefe
SWiofllV.'t^^^
* ahy "Affiliated EfltityM (meaning aperson Or entitythat, difeetly of itidifestly: controls the Discjdsing Party, is cohfrdlied by me;DJseloglhg ^fty, 6r%Mtik;mm^m$Party, uttdef tmrnmrnnwdi Mmis^-^^xit^^^ Indiiaof eo&tfoi teeiade, 'w4u%itiftottttib«i ;mtef1oe|^ 'b|-b:w.ni^^ f^ciiiii^a
tfe{C%. ushtg^ubstentiaily tbewahie maaageihent, b#h^shlb|of pfittcipais as the ineligibie entity); ^lhifegpect%^ the term Mfi difeetly or
inaifeetly ebhtfbis the CpntfaetoVia controlled by it, of, with the Contractor, is Mdef common eofltrbl of another per son Of entity,
* any responsible official of the Disclosing Party, anyCoatraeibf bf any Affiliated Entity or any otherofficial, agent bf employee of the Disclosing l>artyj any Gbntfactof of ariy Affiliated Entity, acting pursuant tothe direction of authorization of a regpoasible official of She Disclosing; Party, any Contractor or any Affiliated Entity (collectively "AgentsM).
Page 5 of 13
WeithM^
or any Cohhcactpf nof any Agents hsv respect-tova ^Contractor i ah Affiliated before the date of aueh Cbfltfaetefk of
raprany Affi^
thefffeyeafs/be^ with ,. Of an A01|aied Bhtlty of a ^
iattty!s
orengai
: in eonngetion
a. bribed or atternpted to bflbsjof beeieo^vie^
bribi, a public officer or employee afttfrC^flil State of Illinois, of^ any agency of the federal goyernnient of of any state Of ipcal^ or employee's offfelatcapacityi
b. agreed of colluded with othef blddefsw pfespeeti^biddeiS, or been a 0By\oiiny sueh agreement, of been ebttvieted bf a(^u4gesl guilty of agreement ot eoilusibti[ anibhg'Bidders Of .proactive biddersrin'rettrafflto fessl£pfieevbr'
's;-of
di ihade an. admission of such ^oftdtt^'d^e^ei^/of'b; above that U a tnattfr of record, but have not been prosecuted for sueh eonduetj or
d. vioiaied the proy isioria; of Mpileipaii Cbde tectte 24i'i0 (Living Wage Ordinance);
4; Neither me Disciosing Party, AfMated Entity of Contractor, or any of their employees, officials, agents or partners, Is barred from contrasting #fth any siiilt of state of local government as a result of engaging in bf being convteted of (1) bid>sigging la violation of 120fLCS 3/33E<3; (2):bid«fbi^iflg in violation of'720 ILCS 5/33E-4; or (3) any sifflilair offfinse of any state of of the tftiited States of America that contains the same elements as the offense of bid-rigging or bid-rotatitig.
5. Neither the DiselbsiflgParty ttoMh^ any of me feitewmg^iists
maintained by the Office of Foreign A^etaCbltfal oflheii.S' 'Deparhneni of Ihe Treasury of the Btifeau of Industry and $ecttrity:.of^
j&i^i||9^:k^euU> List, mVBMe&lefson«ili| 'j^^'iiv^fle^iLM^ Ehlny^islahd^e " /List-
6\ Ihe Diselbsihg Party UflderatartdNhd shall comply with the ^applicable feq^^ P&$ (Legislative mspectdr ^ ofthe
j, Ifthe Disclosing Party is unable tb eertify to any of the above statements in this Part B (Further ; Gertifieatiotts), the Disclosing Party must explain below:
Page 6 of 13
If the litters *H-h* th® word "Nbae,11 of no; response appears on ihe titles i plumed ilaitheDi^
s, iiwilibe cottcloaivety
e,: mmm&mim of status as financial institution
t* The Diselosiflg Patty citifies that ^Disclosing Party (efieek ope) t1 la |$ icflot
a "finaneiajihsn^^ Section 242435(h) ofthe Municipal Code,
2> Ifthe -ttwloihift'Jr^'fil a financial ihstiiuiioii, then the'
are hot and will fldtj
Code; ^e farther pled|g t&t: no^ Isjiand hone of them will beeomei afpredatbry
tehdefasd#nedm Chaolri-M ofihe Mtjittichjiai cede. #e underlie ietider/o^b^ busihess: with the City/
If the jEJis^toai^g, 1^ajfty Ja unajble to fflaki this pt^ag© tjesaw^eVit dri1 aiiy of lia affilMtes <aa defined in Sebtkni i^^(b) of thjj lteiel^ Ihe meaning bf Chapter
242 of the Municipal Code, explain here (attach additional pages if necessary);
If the letters MHA,M the word "None,'' of no response appears ohithe {tines above, it will be ebnclusiveiy presumed that the Disciosing Party certified to the above statements,
D. eEttTIFiCATiOf RfiOARDINO INTEREST IN CITY BUSINESS
Any words br tertp that are defined in Chaptef: 2-156 of thrMiinieipaiCbde have; the same meanings when use^ ih tbis^^Dv
1. in |ecb^fiw^itb p^t^^^i Wat-dte MWeipf .Coie^Dbes any bftiMaiof -employee' ofih¥Ci$ h&vb''a^fiG^tii-2ft0ifii|^^siilri-flls^^ev bWftMnie Of ih ti^<«i^tf»-CFl!i^'«rti&e^p«#sotl-or eatitylh theMattert ;.>,.
■ '[];yW ' " Mo
NOTE; If you checked "Yes" to Item D.L, proceed to Items 0,2. ahdD.3, If you checked "No" to Item D. 1,, pfbeeedto Part E.
Page 7 of 13
% Unless sold pursuant to a process #c^fflp^««'ft^fai^^iii^iB> pefttllited, ho City elested of^al or employes sto any olfief persoa df entity in to
for taxes or assessments, Of (Hi) is sold fcy virtwe of legalpfoeess &i the^ sail of the City (eplleeilVely? "Ci^ WdpertyiSftle'')- Compensation for|fope^faB«t power does not eoMtituma
Doe* tee Matter invote
[jYis um
3. If you checked"*Yes'f to Item D» 1., provide the names and: busings- ad'w^sses of the City officials of employees having such mteresi and identify the nature bfsueft interest:
Name Business Address Nature of Infefesf
4. the Disclosing Party further eertifies matho prohibit be acquiredbyany City official or employee,
E/CERTIFICATION RE&ARDINC} SLAVERY ERA BUSINESS
Please; cheek either I v or 1 below . If the DiselbsmgPafty^^ discfpse below' or in ah abashment to this EDS all ififi^ F^ihtfelo; comply wiihthese^ ' cbnne'eti'ito:^!^
K- l. the; DiselblMg Party verifies that ^MM&m$mHf has searched any and all f^sordsfof meDisclbsing Party and any aadail predeeegsof entitlgsfegafding feeof&bf investments' of profits from slavery bf slaveholder insurance policies during the §^
issued fb slavehbldefs thai pfovided coverage for damage to 6f mjufy of death of thelf slaves), and the Disclosing Partyhas found rib such records.
^J?. The Disclosing Party verifies that, as a result of eoaduetiflg research Ih step 1 above, the Disclosing Party has found records of investments or profits from siavery or slaveholder insurance policies. The Disclosing Party verifies that me follo wingconstitutes fali disclosure of all such records, including the names of any and all slaves Of slaveholders described lb those records:.
Page &p£ 13
1, List below the riabneg of all personsot entitles registered under the federal Lobbying piscldsare;Act of 1995 who have niade lobbying contacts on behalf of uie Diseloslng Party with iespeet to the Matter; (Add sheets if necessary):
(If no ejEplfthatlori appears or begins on the liries--i^^^Miili^Wttt "NA" or if the word "Nona" appear^ it will be obhclusively presumed that the OisctbsmgAty means that NO persons or entities registered under the Lobbying Diselosflre Act of 199^hayeniadeiobt$ifflgcontacts pri behalf of the Disclosing Party with respect to the Mattel)
1 the Disclosing Party haahot apetit and; will not e%®ml any federaty ajipropHated funds to pay \^$MM bryntftyliiitedlin Paragraph} fa*.titisfyfa.^&ffo lobtiphgaeilvliies^ to pay any ' ipirsbbbr ehaiy. to mfluetfce or attempttbanl^
applicable federal law, ajhemberbf Congress, an oMeer or employee o f Congress, of an emplby«sg of a member of Gongress, in connee^
federaiiy funded grant or loan, entering: into any ebbperaBve agreement, or to extend, continue, renew* amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
3. The Disclosing Party will submit an updated eertifieatlon at the end Of each calendar quarter-in which there occurs any event that materially affects the accuracy of the statements and Information set forth in paragraphs A. 1. and A.2, above.
. 4. This Disclosing Party certifies that either; (i) It is hot an prgafiizatibtt described hi seetioh SCH (c)(4) of ihe internal Revenue C ode of 1986; or (ii) it is an brganizatibh described in section 50lM(4)®ftlfe not engage in "Lobbyfhg
Activities'". :! ......
1 iftttefiscibfliflf P#yis1^ fdrm and substance toipatagraphsf Aiirmrb^ghk& Ibbve from ill^s^motiti^^ awafas ahy ■ shbeoapetahdvMie' Discl0sing Partymi&thiah^^ the durafibfr of the Matter and ntust make such certffl to theGiiyitpbn request.
re 9 of 13
B. 'Cfiaflfi&AMdfr BO0AL;>IMi*LOYMiNf 6#©RT tM&TY
tifapMa&tt ia feteliyfM^ ^i^pj0m&^Ml$%bie$
IsiheDIselbsIb^ ,
HYes {}% If "Yes," ans wer the three qaesiiofls below:
1. Have you developed and do you have on-'file-affirraative-flc'flbb-prbg«mB pursuant to applicable federal regulations? (See 41 CFR Part 604.)
yYes urn
2. Have ybir filed wiiibfthe Jbihti^pp^giCd^i^'^ii Director of the Dfifee of Federal Contrast eb^^et^^nti^orr tbe1 Equal Employment Opportunity Cblii^'lisiob'air'i«p^t^ due
under She applkabie filing feqaieenifents? ' - i
liYes [\m
3. Have you participated iii ajtjy previous; contraeta.or mib'eoatraetsMbjlet to the equal opportunity clause?
13 Yes tl*to
If you cheelted^
faction fit - AmmmmmnmtB^cBmuAcr w^MtiMttetf*
COMPLIANCE, PEMALTIES,MSc:idgiJilS the Disclosing Party understands and agrees that:
A. The eertifieatioflSidiSclosufea, and acknowledge willbecome part of any edtttfast of other agreementbetween the Applicant and the City in sonneetion with the Matter, whether pfocttrem«ht»-City._a|sistaiiMV or other City action, aad are materialifidu^^ execution of any contraet or iakmg otkf action with respect to the Matter; f he Disclosing Party understands taai H'ittb$f4ompl'y wifoaJMafctfes, btdiit^ejefli^da^giikg^ i®M$kM0^-kbwdi-.
B. The Gify's QoveffbmeiiMlitbiesiand Campaign Finaneitig Gifdiaa^ses, Ghaptets 2*iMm4 2464 of the Municipal Coder ^ eiikgationronfeht|iie>:^
work, buiiaeBa, or trangaeiions. The full texto^^esed])d^ai|es,a«^#MMa^ pfogfarh is availableon Itee at wyw^tt»dfehfeiteo^i^tt«tcs and may also be obtained from the City's Board of Bthies, 740 N.
Page lO of 13
Sedgwick SWSuite^ CB^^ t>!3) 9669. fhe BisetoBiflg Party tMst ebrhply fully
with the applied
C, if the City determines that ahy InfhMatioh providedha this EDS is false, incomplete df inaecttfate, any e^bactorouWagreem^ it^s sabmitte^may b> rescind or ha void or
widhW©, and;tae?City may ptirsae aay ^ (if notresciaded or
law* bfih^^ iaewdlngtte hi tfi^ Matter an^/or
#$Mtf .to; 9ll^%|^^^tii@N$ pi$ei|£&^^ Wftit&Cliy Rjmeoies;at
ia*y ^rafais« ttt^it^^a&fei^' ffiii&i^
D; ft is the City's policy to make this document available['<d'1$e^Be'6#tfaln4era«t site arid/or tpbtt refu^si Sbnie of ail of the infoimation provided on this bM and ahy attachments to this EDS may be made available to the public on the Infemet, lb fespbhse to a Ffeedom of Infofmaflbfl Act request, br otherwise. By completing and signing this EDS; mDhi&9iiii^^^.iivwaaiA releases any pd&ible rights of elaihis Which it may have against the City in connection with the public release of infofmatibn contained in this EDS arid also authorizes the City to verify the accuracy of any information submitted in this EDS,
B, The ^formation provided in this EDS must be kept eutreat Iff the event of changes, die Disclosing Party must supplement this EDS up to thetime mmymilmi^n on the Matter, if the Matter is a contract blsing bandied by the City*a Department of Procurement to DiselOaing Party must ■update this EDS as the contract requires, tftttffct Wlikrespest t6;Mattefs-subjeet to Ai tiele I bf ;Cfaaptef'i43:of:the Muhicip^
.ofcieskthe information provided^ current for a ibnger period,
.afrfod^pd ^ '' ^A"
.... ^H:1^^.^<r^r-;-^Vv:^',
P. 1 , %e Disclosing Party is not delinquent in fitt'PiayttieftManf^^l^Ms^d by ^ iilfeois WeppmvA of Revenue, not are the Disclosing Party-or its Affiliated Entities delinquent ih paying any fine, fee, tax bf other charge owed to the city fhlS iheludei, but is not limited to, ail water charges, sewer ehafgesi license fees, parking tickets, property taxes of sales toes,
fa Ifthe Diseibsittg Party is the Applicant; the DiseiMihgPatty and its Affiliated Entities will not use, nbf permit their subcohtfactofs to use, ariy facility listed by the U.S. EvP.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 cohtectbrs/subebhtfactbrs hired or to bs hired in eontteetiofl with me Matter certifications equal in form and substance to those in F.l. and M. above and will hot, without the prior written consent of the City, use any stick contfactof/sttbcontfacto
Disclosing Party has reason to believe has not provided of cannot provide truthful certifications.
Page11 of 13
explanatory i
^neBUomM^nf^mmmbim msm Ap^endia -a w appiieabie) are tnieVaceariue
a^i eoniplete
iprtybename of Oisebglflg Party)
(Print or iffi^t-bypi^'itsjfiig).
(Print or type mte of person signing)
Signed and sworn
tti before me on (date) A|V 15^ ^ County; MY Mate!
^btaiy'P'ubii'C';;
. ABIGAIL A. BECKVVITi.
■:--0^?V P'JBUC-STATf OF New YORK Wo. 01BE6216060 Outlined In New York Counly "■' Commission Expires January 11. 2014
Page 12;0f 13
WAXttiffibti^ ELicrrEi) city officials-Am^mmmMm h&Ads
" ii()&^^
any 1
■ wliM Mas a direet 1 afly kgal eutity
i|r«ttfidalw
sighed, the Olseiosiiig Far|y or afly "Applieabl§ Par^' ef fay I themayor, any alderman, the city clerk, die city tfeaMferofj
mpst dlselose whether such Disclosing Party has a "feminftiyaaonsbJp" with i*' eidsts if, as ofthe date tills EDS k of^dfn^MfAM^%^io{is related to as spouse or domestic
partner or as ahyof the Mowing, whether by blood of adoption; parenti chiidi brother of sister, aunt or uncle, niece of iiephew, grandparent, grandchild, famef%4aw, motfi^ stepfather of stepmother, sie^^^
x" means (1) allexecutive officersafilie JEJIsblosirig:Pmly llstetl in Section fl.B-La., if the : isi acior^fatipfi; all partners of we Di8closinfPafty,;lf the OiMdSMg Party is & gehefal p^^sl^pf a.U gmeral partners and limited partners"of dies piselM^ is a limited
partferShlbj all hianagef^ htah^ Diseteain^;Pa%i if tne DisdoMng Patty is a
TiWified M officers of the Dtepsihg Parly; ahd;(3); any pefgonhayihf more than
M p^eHtdwhefshh) interest in the Disclosing Party. "Principal ofncera" means the president; chief bpfra1bigpffleer,;e
Dbis ^ Parry" ot;
a 'TaiffiHat^ city official br<
ase br Opmestle Partner thereof currently
No
(
^0^^0yW^ ^)^ name and title of stteh p^bh,:^).m^name^of the efsbn Is Conneeted} (3)1he nanSe and title bf theieleeteo ci^ pm0bk a j&mjjial relationship, and (4) the precise nature of such ffimihal
entity to which to whom such
Page 13 of 13
m Chicago seo&oMiCDisci^
'A1W-AfMiAVVt
mmim oiifiML m formation
li^m®MtmQui miil|^n8^a%so)»iiiIftitig tills EDS is: 1» i ] the Applicant
2. j$ a legal entity holding a direct of indirect Interest in the Applicant. State the legal name of the Appikaaf In whieh theDisclosing Parly^ holds an interest:/ " * ~ "* -> -
3. [ ] a legal entity with a right of eoflifol (see SeMOn ll Jvl v) State the legal name of the entity ih whiehthe Disclosing Party holds a right of eomrel:...__
B. Btishiel&i
Disetesiflg Party:
C. Wmhm^ £\%*&>\<\$s% .Mm-^r^,W3h .. Email: jaAu^^W^
Ei Feo^llhlploylf IdehHfieatmtf ^o. (tf you have i.....I ^HWHMWBP
P, Brief deseriptfon of contract, ttaMactibn or other tindertaklttg (referred to below as the "Mattef) to which this BOB pertains. (Include project number and loeatibn of prbperty, if applicable):
Q, Which City agency or departmentis requesting this EDS?
If the Matter is; a eoatfaet belnghandled by the City's Departmeht epmpteteihe following:
fpacification^.
v«p.siKei-ie
Pagitbf 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
I. 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
[ j Limited liability partnership
[ ] Joint venture
[ ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
U Yes H 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?
tlYes ^No UN/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 titlebolder(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
Vft\\<.<N V\ VkVto 9xtA V\ttVr_;_WVmJ^ Hwf"^ (->wr^ U*A\StifiNv^
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% ofthe 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 ofthe Municipat Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Business Address Percentage Interest in the
Disclosing Party
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disciosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[JYes ^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 Disciosing 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 ofthe 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 either ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name
(Add sheets if necessary)
^Cteck here trih# fil8el0ili| Party Ma M6i rgtobi«44 ttomp^eisib ret^
A-SdmT.OI#£RE^£HlLP Under Municipal ^
the eity must remain in fiompH'aiBcf wlln tfieirsMild Support obligations ibfbugb&ut 4hi isbniraifs term.
Has any pgfson who difeeiiy bf indif©s# owns ido/o of more ofthe i6lseibs;ihjf^W^;d^lM^''te arrearage on any ehild support obligations; by any Illiabis court of competentjUfisdietioh^
'(] tea (j So MMq pefson directly or mdireetly owns t0% of moife of%<s,
DiselbSing Party,
If "Yes/'has the person elitgredittio^^ payment of all auppbrt owed and
is?the persbn in compliance withirihaiagr elnientt
[JYei fJKo
B. FURTHER CIRSPtCAf iONS .
I. Pursuant to MunMp^f ode Chapter, i^ArtieiM ("Artiele1^*^$* $0km0^
ebtisuit for mtmm^^g.^i^ toshiesf^aia^
■'Sifljffl'itting Party"
certffles^ fcliowsi#fi^
with, or has adffliftediguiilt of, or 'mm^mM0fad oft of ahy ertmiiaal offense invblviiigaetual, aitiniptei^^^ the^ffaadi fbfgefy,
perjury, dishonesty of deceit against ah offleer of etaployee pfShe City of any ^ .01) die
Applicant Understands and ae&howie^ with Artieie l is a ebnlMing fe^uiremem for
doing,business with theie% HOf 1: if 'AStkti^trtotoe.Afaltem*fafttmmattiomplfettce, timeframe in Article 1 supersedes some five-year somptiahee timeframes ft eeftifleations 2 and % below.
Pap 4of 13
ideptiiie*f tajesilbh ilJ>l,bfthis EDS*
fParty is; a ieiai^ani%r.att4o^til0i^;
I of
a. Urn not pfea«n% debarfed, suspended, proposed fbf 4ll)iatik^^lM^ii{e^blii-df voluntarily e»^lUdid froni M
b.
it V|
have not, within a five*year period preceding the dais of ttiis BBS, been cehvieted of a erimihai offense, adjudged guilty, pbtaining,^ attentp^ibt tbbbtain, orperfoffflifit a P*>bl3e (federal state of local) tfansaciibb bf contract under a public transaction* i violailsi of federator state s^^^^ erbbezzienieat; theft; forgery; bribery;, falsiflcatibn of dsstfuetibn of records; ma^ng:
c ^;fcbi;p^
isfete of- ibeal) 'with; eomthittihg mf oftk bffettseB set: fbrthlia ei^se-teSfe, bi M "
d> b$yt^p% within a:
Wt^MdW(f0^Ut^s-ot loeafytennkated fotfcanse of 'd^bjltri&d
& have hot, Within a frve-year period preeeding th© date bf this EDS, beeni cbnvieted, _ _ _ guilty, dr found liable in a civil proceeding, or in any efiminai bf civil action, including aetions cojieefning environmental viblatiohs, instituted by the 'City or by ihtf&d0Ht geif4Tnitit0( my state, or any other unit of Ibell goyerhttient
34 fhe^ertifiealib^
the Disclosing Party;
any^Cbfliiae^
eonneetion with tae#attef, incltiding bat hot limited to ali persons or legal entitles disclosed under j^tioii .IV* '*^S^«i«Mii« ■o/9.ttd^&Bc«Mtf:iittd ptiifi^r. R<eitiim«<t
atty ''Affiliated Entity" (meaning a peraon of entity that, directly or-indifeetiy: eontrbla the Disclosing Party, is ebntfoiled by meDiselosihg Par^, or is, wiih the" Diseiosing Party, aQ^ef eomnioh eohtrbi of ahbthef per son of entity, indleia ofedntfoi melude, without limiiatiofc tfltefhp^
;andle|j|ti|pipt5 eohihioh use-of^^i^^ UWmM$ the
:toel|ibifty.b ^ieorioeai govefh^^ ■
#8/City-^mg^absiantially theMme ittanigement ownership; br pfmeibals asfhe ineligible entity); with r#8pet/t9 Contractors, thetermAffiliated Entity meatis a persbtiofentity that direetly-of ihdi^eily sbbtrbig the Contfaetof, is eofltrblled by itj of, with tite iontractof, isundef eomnjoa control-of another person br entity ;
^^^:i^i|l»^ti)ii!$ii» ofiEI%'isil -o'fr^«--0ss«to8ia8Ci^8ift)^ any extractor of any Affiliated Enii# or any other offieiaij agent bf employee of the Disclosing Party, any Contfaetbr or any Affiiiated Bhtify, aetiflg pursuant to the difeetioh of atithofi^ation of a responsible official of the Disclosing; Party, any Contractorr-pr any Affiliated Entity(eoileeflvely !lAgehts")*
PageSef 13
1
(
$e|m®r tip-MkeimkfJP^Memuf, bYahy^bh:^
respect te a Cbhtraetbf, ah AMiiated before the date of aueh Cbnifaefe's Matter;.
th^'fl#y;e^ie^|:the alibis fiDS^ is islgiied* or, win V or-an^iiiiafed Entity of a ohtf^etordarhjg' tte$.fly'f yfc^. edntfact^
or at
ig4 or
of ac
_ w^^^.,^ r. ^»^i"gttilty bf bribery or attempting to
ribe^ aptiblle offleef or employee of theCity,; the tteiej bf llUbbls, or any agency of the federal govepbieMor of apy atate ofloeal gbverhtffei|f # ^^y^^fifttes ofA^efiea, to mat offleef's
b< a;
ibidders, in festMitif Omerwiaerof
M .eoibsiOh amdhg'bldaefS ol ^ompefit^ bid a fix^d prlee or
stt^aiD:adna88ion^of'saeh cdhdb^4e1^bilcl'#'a, d*b> have hot beep prosecuted for sueb eondaetj Of
i that is a matter of record, bttt
J& vlblatsdtbepfo^isibfliof Maaiei^
:4 Neither the Disclosing Party, Affiliated Eatityof Cohtraetorj of any of theif '<__,.-, _ ,_____
agehtsof partaerS) is b&jrea from coat^
engaging ihbr being eoflVlcted of (1J hid<*iggiflg in Viplfttiofl bf 720 ILCS 5/33B-3 j, (2) bid»rottftiiig- in violatioaof3&6itCS S/33S-4; of (3)any similar offense of any state of of the United States of America pat contains the same elements as the offense of bid-rigging of bid-rotating.
3. Neither m^ is;iisfed^h any, I
maintained by theDffiee-of &®$mm®ni®Bh% feasafy of the
Bufiauof IndM :W^Bi^^idf&0^$^m tl^^um&rs^i^Mp^^fy
Dejtgnated i^tfbflalf ih&lbii fitenled Persons4^^'Uh^ifM#a £fs'tj^ " OebaffedLiafi
-ji. f he Dis^ibsiiig party understands and shali comply with th© applie&bie^ulfemehi&\bf/Chapters. (Legislative Inspector General), 2.56 (Inspector General) and\i°i$6 (Governmental Bibles) of Jhe=
% If the D isclosing Party is unable tb j Certifieations), the Disclosing Party must <
t to any of the above statehtehts in this Part B;'(Farther
Page 6 of 13
L The Disclosing Party certifies that the Disclosing P
[lis ^ is not
a "tlnaheiai instiiationH as defined in Seehon 2^32^35(6) of the Manieipai Code;
2. if M Diselosh^i^rty IS tf finMelal gstftutoa, then the Disclosihi Party pledges:
" We arehai andwillfldt^edme;a predatory: fen defined ;ih' Chapter2-32 of the:Muflicipal CoW, We further pledge thatnonetffottf affiliates ia, and hone of them 'Will:&ee^me'^a^eda^bry lender as defined in Chap ter 2*32 of the Mutf ielpal cede; We andarsfafldihat^ lender or besomingan affiliate of &:$fedatdry iendef may result ih the loss of the privilege Of dding^ J easiness with ihs City/
If the Dfeeiosih| Party is t^ble%#a^^ of its affilifltes%s defined in
S eciibn ;2*3>4Bfh) -of -the* Mbniejp^ wiralh the hieahihg-of Chapter
2?32;of the Muhleipal Code, expiain here fattaeh additiohal^pages if neeessary}::
If ihe letters "N A ," the word "None," or no -^^ji.App^'0,ikc. lines above, it W ili be conclusively presumed thatthe Disclosing P^ certified to the above statements,
D, ^RTIFICATION
Any words or terms thai are defmed In Chafier 2*156 ef the Muhicipai Code have the same; ffleanihgs when used inmis Part D.:
li l|#eordanee withSestib Manlb^iiJGoa^ ofiiaCiryha^e a financial interest &hiseo^ pefsph or
,enn%)ih .tie MstM1
tft&."""" j$|fte
i^DTE; If you cheeked "Yes" to ItemDj., pfoeeed to ItehisjD2. and D.3. If you checked "No" to Item D.l i, proceed to Part E.
Page 7 of 13
3, Uiriegfr^ eleeted offl^ial of
any offier^bwnbr gfttity inr the pttfisn^se of iiiypfbhe^
for taxes oi* ^gs8ffleti%of ill) Is sold fey virtue of legal pfde>ss at tfel t^i^'^j6^^iis^^i
mi
;of.thiapWfe
Sale").
;het«^
Does the'^atterinvote^ B tj Y«f tlNo
3. If>N^--c1i<^|^'M1r1^^'id:-if£m iU-., provide the names and
offieials of empldyees haying sueb. interestaad identify tbf haturi ofsilefi interest;
power
bfthrClty
Name
Matafe'bf ibterest
4> the 0i8elbsihg Partyiflfther certifies'-.that no fjfohibited finaneiai W &CEMTFiC&T?^^
Pleaie «beek;e:Mef l.br2. below. If'dieDiselbsing Pa^ehe^kfei^'dje 0i8c1dsihg;P^;miaist, disclose below or in-an attaghoie|ii to>thls WpM^d^im^^^'M^ ^^04^ Mhp-fo coffipty with these dis^bBjirg fe#if®nfeata:ffiay 'nfakf Sny^pfilr aei;en$e*e| felisi-rWiib'trie ©X^ttf eonh%?iiph4Yim^ '
-j. The. Diselbs'ing Pjrfy verifies; that the Disclosing Party has" seaifehed-anyindjatf reeoida of. the Diseasing Party and any andteii predecessor enh1B8ft:^|a1#i|;f^faibf invesiments or polls from slavefy bf sla^vehoi'd^
iiBued to slaveholders thai providedcoverage for damage to oj? tejtttfr-or death of .tibiefr'-*lavei)» arid'-'tf«. Dlsdoiittg1fer$ has fb?!tuid;tt^'aiic& records*
__2. The Diselosiag Party verifies that, as! a tesalt bf ebhduding the-search in sttp i above, the
Diselbsihg Party has fbahd reeords of investaienta br profits from^ slavery of slaveholder insurane® policies. TheTJlseioslngParty verifies that the following conMitute^ stteh reebfds, ine Wding the namesof any and all slaves or slaveholders deaecibied in those fgeofds;
Page 8 of 13
^0 MATTERS:
iom
lhis:§e$bnVI. If the Matter Is not I &ts mi Mm
.A, ciI^Ica^
I:* Listbelbw tte names of all personsorehtities registered ander the federal Lobbyihg; ^1M6a^A^^iWSp^1m9 maaVibbbylhfe^ :respeet:tb ihe Matten (Add sheets if heeesaaryjj
sv dr if ffie leftefs "NA" of ifthe word "Kong" ?ttIselosmg^ n9#bayemadsyte^
(If1 ao espiaoatioti appeafsvdf begins otithe appear,it will be eonduslvely presumed that tl fi|isiefed qniMttie Lobbyihg DlkfosHfe Aet i Dkclbslng Mrty;widt jt^biet'tb-.ttie Matter.)
2. The Disclosing Party has hot spent and will hot expend any federally appropriated funds to pay any person of entity listed in Par agrapb A. i. above for his of hef lobbying aeti'yHies of to pay ahy person Of entity to influence of attempt tb htflaeaeeranoffieef bf ehiployee of any ftgeftey; as defined by ^l^bji'iydeMjiaw, a me#er of Congress, att offleer-oriemplb^bf Cbn^sS| of art employee of a Mentb^fbf Coagfess, iti epnlectbsnwlbthe awai^bf^yfeb^
fatally:tpi^d;^mm;pMt^ e^tt&ififoextend,; cbhtmbe,'r#hew^. -. arhendj $$a$lffmy. fe^iefa%fu;niled c^aiae^i griflC Iban, or cobperative ajpeiflent,
3. f he Disefcsiag Fa^ at the end of each calendar quarter in whlish there oleto ahy tivehtihatmaterially affeets the aceufaey of the staterhenis and ihfohnatioh set forth ih plifagfaphs A; 1. and A.2. above.
4. The Disclosing Party certifies that either, {i) it is ndt&tt organisation de^
301(c)(4) Of the'Internal Revenue Code bf 1986', bif (ii) it is an organfeatibn described ih section M(C)#) bf the Internal Revenue Code of fbge but has hot eflgaged and will not engage in 1 Aetivities".
3u If the" Disclosing Party is fe Applieant, iM BiseipsihlMtfyMxsi Obtain ^rtifieatibhs epal itt formandittb^
sub^bai&fcaad ttie bigeiosfef Party isiMt^ia^^i^/.i^^sueh subeoatfaetbfs' eertifieattbtis for the durationxbf tie gaiter and must map s^ upon request.
Page 9 of 13
funded, fedefail
rtosuJmW&s^ MgotMidhs.
i ■
is the Disposing Pat^
[JYes [JNo If "Yes," answer the three questions below:
1, Have yob developed and do you have on file afflrniailVe aetloh programs, pursuant to applicable federal regulanoas? (§ee4rCF& Part 604.) [].*«»' t IHo
% Have you filed Wim tfceJfciiftft^
Contract^
under the appiieafel© filing fequteemgflts?* [JYes tlNo
3, Have yoji\par^'eip^ed#:My.p^ibn> eohttaets or subeohWets subjeet to the e^naioppbftun% clause? fifesi' \\m
If you checked "Nb" to question 1, or Z.-above,;
i provide ah explanation:
tii - acknowledgments, contract incammA'pion,
PE^ALTlEi, DISCLOSURE, the Disclosing Party understands and agrees that!
A> the certifieatiottS^ contained kthia EDS will %<®orte$ati;dSkny_
contrast orothef agreement between ih® Appli<i$nt^ lty;msebhneetion;witb ^M&m^MMm proetiremeflt, ;^i% assistance, of other City action, and atp material inducements to the City's execution of any contrast or taking ©thef action with respeet to the Matter. The Disclosing Party understands that iiahuatedMply ' '
B> The Clttyfs Goveratnehtai Bthies and CampaignMmtMttg Ofdihaoees, Chipters 2-1-56 and 2-164 of theMunieipal Cede, impose certain duties and obligations onpersons of entities seeking City sohtfactSj work, business, or transactions; the full text of these ordinances and a trainiflg program is available on line at wwf .citvofchkago.of a/Ethlcs. and may also be obtained ftom the City% Board of Ethics, 746 N>
r
Page 10 of 13
SediwiefeH,^m.{mali^il60*1^(312}tmm* nemdminsPammmmplyfully withihe; ^---^ '
■ Ordihariees.
C. If the Ci^ieienm^ jij th& eds is: false, Iheothplete or 1
aa)j cdfltfael ^ with-wbieh &;te^|^^^.j^|li^.Wi voidable, and*fcee^
^atla^fTiii^uit,^
law far a fals^s^ieitteatbif ntatirMfad may iheiiMe iheaieeraiida-and ah iMl#l%^^%^Mle.
D. 14 is the Cityls polite wake misdoeumentayaflahfe te the ^&ofi1^Io^tm.aBMup«]i: request S«tiw-wa'tf dflh;e^
made available to tfiepublie an the Ifltemet, hi response to a Freedom of Informattott Aet request, or otherwise. By eompldiag and sighing this EDS, the DisdosingVPartywaivesand releases any possible rights prcl«lmarw;WfJn.to'a:y haveapiast the City ih ebaheetioa With the publie release of ibfofhiatipa contained in mis EDS and also authorizes the City to verify ffie*&uracy of any Information submitted la this EDS,
E, The information pfoviaed In this EDS must be kept esirfeflt. In the event of changes, the Disposing Party most supplement this EDS up to the time the City takes aetibn on the Matter* Ifthe Matter is a eontrad being handle
update this EDS aa theleontfaet feplfga. NOTli With fespeet to Matters subject td Artiele 1 of Chapter: 1-23 of the a«nieipafe<^ettepdslng VESMAimtT :tmtmmtijm tot eertaiaispeeified omDm)^<^mt^m^4M k¥*& tifa&toibti&b^ rhumhe kiptebrrto for a as required by Chapter 1-23 mmmmMM$2li of «te MMie&aifcade.
represents and#affaatsitbat;
F. 1. The Disdosiag #arty is not Department of Revenue, nor are the flue, fee, laa of other ehafge owed to sewer charges, iieense fees, parking
ieht ih the payment of any tajt adhthiistefed by thr Illinois '
oritsMfitiaiM Ehiitiesdeliriquenf inpayhigany City. This ineltides, but is not limited to, ail; water ehafges, i property taxes of salertases.
F.2 If the Diselosing Party Is the Applicant, the Difidosiflg^P.aftyand its Affiliated Entities will not use, nor permit their Stibcontfactofs to use, any facility iistedliy the D,B, E\P.Ai bfl the federal Excluded Parties List System ("EPLS") malatained by the U. S. General Serviees Administration.
F. 3 If the Disclosing Party is the Applicant, the Diselosing Party will obtain from any contrastors/sttbebntfadora hired ot tbbe^ hired in eonneetion with the to form and.substahSeetothose hi:F.I. and F.l above and will not, withottt fhepfiof written consentof th« CltyVttir*"^ not provide each eertifieatibns or that the
Disclosing Party has reason tb believe Has not provided or eannot provide truthful certifications.
11 of 13
explanatory stltemenirnustb^
-'1J.ii^fer;:f»dti^^ ^i»«urj:vf^v^e .P^fspii'M^^S below (1) waitaltsithat he/she Is authored to exeeute ihis.il^
, fig^ifle^rtQfi* ari^ stetem^ta ^ontaiiied ill this EtiS and Ajjjpsftdii' A (if ^pileabte) a*e aceiiSfate ahdcdttipie^
or type name ei§ Piselosifi;
(Print or type hame of person aignui
(Print or type title of person
Sighed and sworn to before me on (di at', &J:YL. County,
xrsiJL«L
Commission expires: 1 li H
ABIQAifc A. eiCKWITH NOTARY PUBUC-STATf OF NEW YORK No. 01BI6216060 Qualified in N«w York County My Gomrtiission %np\m Jenuoty 11.2014
Page l lbf 13
Mm&Mctitmmsvm m&rmmt and ,
FABllLIAi:IU2^ AMD DEPMTMfirfr ttEAftS;
til-to'h^eotbpleted ®a%.By(a)ilig'
wlikSi toa-tllfs any legal entity
UhderMtini^ of any "Applied
ahy elected city official or a^artiMedtlieaai A familial rel^onibip" estists if, as of-the dale this EDS is signed, die Diselosing Party of any;^
the mayor, any alderman, the city elerkV the city treasurer of any city deparMent head as spouse or domestic partner of as ahyof the following, whether by blood of adoption; parettt, ebild, brother or sister, aunt of uncle, hiece or nephew, grandparent, grandchild, fathef»ih-iaw, nSbthef-ih4aW, son»in4aw, daughter*ta4aw, stepfatfief or stgpntolher, stepson of stepdaughter ;^stepbrother or stepsister or half-brotherofhalMstef.
! Party" means (1) all ^eeutive! officers of the Disclbsing Parh/'lWe^-inJe^oh.ilElia., ifthe /l*:a-edip^^ori^;p%pe^ of the DiseiOTibgPariy, ifthe bteelosing Party is ageneral p; 0m^'P^m»mll%i^pgihm of th® Discloshig Party, if the Diselosing Party is a limited
«-<------P5 allwanagefs, thahagina membefs and members of the Disclosing Party, ifthe Disclosing Party ii a
limited liability company} (|)aiiprlneipaf officers ofthe Disclosing Vatifc and (3) any p^on having more than a iJ percent ownership interestin the DiscIpsihgPai^ pf^sideh^ chief
derating officefi e^eetitlv^difectbf,chieffiaMieiai officer, treasurer of secretary of alegaietitity dr My person -afeetefttag sihtii^/afpo^^- ■ ......
lorDomestic
Does th> Disclbsml P^ have a '%miiifii^
I 1 Yes
No
If yes, please identify b^^ such person is cotmected; (3) the to pefson has a familial feI#onsM^
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I GENERAL INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
John_Hancock Holdings (Delaware) LLC_____
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. a legal entity holding a direct or indirect interest in the Applicant. Stale the legal name of the Applicant in which the Disclosing Party holds an interest: MDE Thermal Technologies , Inc .
OR
3. [ | a legal entity with a right of control (see Section II.B.l.) State the legal name ofthe entity in which the Disclosing Party holds a right of control:__________
8. Business address ofthe Disclosing Parly: 200 Bloor Street East ________________
Toronto, Ontario.Canada M4W 1E5
C. Telephone: 617-572-9245__Fax: 617-572-9269 Email: j Wallace® j hancock . com
D. Name of contact person: John T. Wallace_
E. Federal Employer Identification No. (if you have one):j
F. Brief description of contract, transaction or other undertaking (referred lo below as the "Matter") lo which this EDS pertains. (Include project number and location of property, if applicable):
Extension of City Use Agreement (Amendment #26) _ _
G. Which City agency or department is requesting this EDS? DOE/CDOT
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification '/_______________________and Contract ii_ _ _
Ver. 09-01-10
Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
!. Indicate the nature of the Disclosing Party: [ ] Person Limited liability company
[ ] Publicly registered business corporation [ ] Limited liability partnership
f ] 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: Delaware
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the Slate of Illinois as a foreign entity?
[ ] Yes RNo [ ] N/A
B. IF THE DISCLOSING PARTY [S 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 tilleholder(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
■ Please see attached
2. Please provide the following information concerning each person or enuly having a direct or indirect beneficial interest (including ownership) in excess of 7.5% ofthe 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 lo Section 2-154-030 of the Municipal Code ofChicago ("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
Manulife Financial Corporation 200 Bloor Street East 100%(direct)
______ Toronto Ontario Canada
M4W 1E5
SECTION III BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Mas the Disclosing Party had a "business relationship." as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the I 2 months before the date this EDS is signed?
[ 1 Yes [>J No
If yes, please identify below the name(s) of such Cily elected official(s) and describe such relation ship(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 ofthe 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.
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 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 Parly has not retained, nor expects to retain, any such persons or entities SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415. substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes ( ] No f^No person directly or indirectly owns 10% or more ofthe
Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of ali 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 I")(which the Applicant should consult for defined terms (e.g "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of. or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Anicle 1 supersedes some Five-year compliance timeframes in certifications 2 and 3 below
Page 4 of 13
2. 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:
a. 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;
b. have not. within a five-year period preceding Ihe 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;
e. are not presently indicted for. or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any ofthe offenses set forth in clause B.2.b. of this Section V;
d. have not, within a five-year period preceding the date of this EDS. had one or more public transactions (federal, slate or local) terminated for cause or default; and
e. 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 Cily or by the federal government, any slate, or any other unit of local government.
3. The certifications in subparts 3. 4 and 5 concern:
the Disclosing Parly:
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matler, 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 Parly, 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 Ihe 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 ofthe 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:
a. 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;
b. 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 f prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
c. 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
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Parly, 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 ofthe United Stales of America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following 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.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Parly must explain below:
The certifications in subparts 2,3 and 4 above pertain solely to the
Disclosing Party and those persons and entities that, directly or indirectly, control the Disclosing Party._
Page6of 13
If Ihe 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.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that the Disclosing Party (check one) [% is [ J is not
a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.
2. 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 ofthe 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 ofthe Municipal Code, explain here (attach additional pages if necessary): N/A
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 ofthe 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 ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[JYes No
NOTE: If you checked "Yes" to Item D. 1., proceed to Items D.2. and D.3 If you checked "No" to Item D. I proceed lo Part E.
r
Page 7 of 13
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively. "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Docs the Matter involve a City Properly Sale?
[ ) Yes [ ] No
3. If you checked "Yes" to Item D.l., provide the names and business addresses ofthe 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. Ifthe 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 comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
rhc Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued lo slaveholders that provided coverage for damage to or. injury or death of their slaves), and the Disclosing 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. Trie 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:
Page 8 of 13
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 ofthe City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
I. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or ifthe 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 lo pay any person or entity to influence or attempt lo influence an officer or employee of any agency, as defined by-applicable federal law. a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract; grant, loan, or cooperative agreement.
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 ofthe statements and information set forth in paragraphs A.I. and A.2. above.
4. The Disclosing Party certifies that cither: (i) it is not an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or(ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
5. 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 il awards any subcontract and the Disclosing Parly must maintain all such subcontractors' certifications for the ■ duration of the Matter and must make such certifications promptly available to Ihe City upon request.
Page 9 of 13
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:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
I ] Yes [. J No
2. Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No
3. 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:
SECTION VII-- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and 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.
B. 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 obtaincd from the City's Board of Ethics, 740 N.
Page 10 of 13
Sedgwick St Suite 500, Chicago, IL 60610. (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
C
C. Ifthe Cily determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under 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 Cily. Remedies at law for a false statement of material facl may include incarceration and an award to the City of treble damages.
D. 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 lo (he public on the Internet, in response to a Freedom of Information Aci request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible l ights or claims which il 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 ihe 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 t-23 of Ihe Municipal Code (imposing PERMANENT INELIGIBILITY forccrlain 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: '
F. l. The Disclosing Parly is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, bul is not limited to, all water charges, sewer charges, license fees, parking tickets, properly taxes or sales taxes.
F.2 Ifthe Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entit ies 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. Ihe 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 thai the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
Page 11 of 13
NOTE: Ifthe Diselosing Party cannot certify as to any ofthe items in F.l., F.l. 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 ofthe date furnished to the City.
John Hancock Holdings (Delaware) LLC (Print or type name of Disclosing Party)
.--"7
By: .....___________
(Sign here)
Brian Collins (Print or type name of person signing)
Vice, President (Print or type title of person signing)
Signed and sworn to before me on (date)_____,
at Suffolk............County, 5°^,m.°^ffIE!\siSef assachusetts
l./s-'f.i>. Y Y'h:t/.4Pi( y.-<ir>c/th:t.t-f-__________Notary Public.
Commission expires: igf& Am4 ^"^CfflCORAN ^my*"~. "fotary Public
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 (hereof 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 ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law. daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers ofthe Disclosing Parly listed in Section II.B. I.a., ifthe Disclosing Party is a corporation: all partners of the Disclosing Party, ifthe Disclosing Party is a genera) partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthe 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 [ JNo
If yes. please identity below (I) the name and title of such person. (2) the name of the legal entity to which such person is connected; (3) the name and title ofthe 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
John Hancock Holdings (Delaware), LLC
CHAIR. PRESIDENT
Lynne Paltcrson
DIRECTORS
Brian Collins William Langan l.ymic Patterson Amy Stengel Jeffrey Whitehead
VICE PRESIDENTS
Brian Collins William Lanyan Steven Moore Kriy Raindial Jel'fery Whitehead
Administration ami Treasurer Treasury
OTHER OFFICERS
SECRETARY lleaiherllill
Septemher 23. 2010