ORDINANCE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICA GO:
SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all the Cl-2 Neighborhood Commercial District symbols
1-1 in the area bounded by
and indications as shown on Map No
the alley next south of and parallel to West Chicago Avenue; North Western Avenue; a line 48.95; feet south of and parallel to the alley next south of and parallel to West Chicago Avenue; and the alley next west of and parallel to North Western Avenue,
to those of a B2-3 Neighborhood Mixed-Use District and a corresponding uses district is hereby established in the area above described.
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SECTION 2. This ordinance shall be'in force and effect from and after its passage
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and due publication. :
Common address of property:
740-742 North Western Avenue
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CITY OF CHICAGO -> APPLICATION FOR AN AMENDMENT TO IaJ+/& O £> &
- ADDRESS of the property Applicant is seeking1 to rezone:
- 740-742 N. Western Ave Chicago, IL
- Ward Number that property is located in: i ;
3. APPLICANT: Mia Property Acquisitions, LLC
ADDRESS: 2853 N. Pulaski RcL Unit CS
CITY: Chicago STATE: IL ZIP CODE: 60641
PHONE: (312) 782-1983 CONTACT PERSON: Nicholas Ftikas. Esq.
Attorney for Applicant
4. Is the Applicant the owner of the property? YES NO X_
If the Applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed.
OWNER: Edward Miller Trust c/o Elaine Miller, Trustee ADDRESS: 3703 W. Irving Park Rd.
CITY: Chicago STATE: IL ZIP CODE: 60618
PHONE: 773-279-9900 CONTACT PERSON: Elaine Miller
- If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:
ATTORNEY Law Offices of Samuel V.P. Banks ADDRESS 221 North LaSalle Street, Suite 3800 CITY Chicago STATE: JL ZIP CODE: 60601 PHONE: (3121 782rl983 FAX: (312) 782-2433
- If the applicant is a legal entity (Corporation, LLC, Partnership, etc.), please provide the names of all owners as disclosed on the Economic Disclosure Statements
Bart Przyjemski, Manager, 100% ownership interest
- On what date did the owner acquire legal title to the subject property?
- 1978
- Has the present owner previously rezoned this property? If Yes, when?
- No
- Present Zoning: Cl-2 Neighborhood Commercial District Proposed Zoning: B2-3 Neighborhood Mixed-Use District
10. Lot size in square feet (or dimensions?): 5,335.55 sq. ft. (approx.)
- Current Use of the Property: Vacant property that is currently being used as a parking lot.
12.
Reason for rezoning the property: The Applicant is proposing to develop the now vacant parcels with a new three-story six (6) dwelling unit all residential building.
13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)
The Applicant is proposing to develop the now vacant parcels with a new three-story six (6) dwelling unit all residential building. The proposed building will be approximately 40' in height. There will be six (61 onsite parking spaces located at the rear of the subject property to serve the residential building.
- On May 14, 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)
YES NO X
Written Notice, Form of Affidavit: Section 17-13-0107
December 5, 2012
Honorable Daniel Solis Chairman, Committee on Zoning 121 North LaSalle Street Room 304 - City Hall Chicago, Illinois 60602
To Whom It May Concern:
The undersigned, Nicholas Ftikas, being first duly sworn on oath, deposes and says the following:
That the undersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Zoning Code of the City of Chicago, by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and on the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of the public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said written notice was or will be sent by USPS First Class Mail no more than 30 days before filing the application.
The undersigned certifies that the notice contained the address of the property sought to be rezoned as 740-742 N. Western Ave., Chicago, Illinois; a statement of intended use of said property; the name and address of the Applicant/Owner; and a statement that the Applicant intends to file an application for a change in zoning on approximately December 5, 2012.
The Applicant has made a bonafide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Zoning Code of the City of Chicago; that the Applicant certifies that the accompanying list of names and addresses of surrounding property owners within 250 feet is a complete list containing the names and last known addresses of the owners of the property required to be served.
Law Office of Samuel V.P. Banks
y: Nicholas Ftikas, Attorney
Subscribed and sworn to before me this S day of^Ct^eQQ.0U.
Notary
ft. ~
OFFICIAL SEAL DENA M ANT0N-PUCCILL0 Notary Public - State of Illinois My Commission Expires Nov 2, 2013
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NOTICE
Via USPS First Class Mail December 5, 2012 Dear Sir or Madam:
In accordance with Amendment to the Zoning Code enacted by the City Council, Section 17-13-0107-A, please be informed that on or about December 5, 2012, I, the undersigned, filed an application for a change in zoning from a CL2 Neighborhood Commercial District to a B2-3 Neighborhood Mixed-Use District, on behalf of the Applicant/Contract Purchaser, Mia Property Acquisitions, LLC, for the properly located at 740-742 N. Western Ave., Chicago, Illinois.
The Applicant is proposing to develop the now vacant parcels with a new three-story six (6) dwelling unit all residential building. The proposed building will be approximately 40' in height. There will be six (6) onsite parking spaces located at the rear of the property.
Mia Property Acquisitions, LLC, is located at 2853 N. Pulaski Rd., Unit CS, Chicago, IL 60641.
Edward Miller Trust c/o Elaine Miller, the current property owner, is located at 3703 W. Irving Park Rd., Chicago, IL 60618.
The contact person for this application is Nicholas Ftikas. My address is 221 North LaSalle Street, Chicago, Illinois 60601. My telephone number is 312-782-1983.
Very truly yours,
***Please note that the Applicant is not seeking to purchase or rczone your property.
***The Applicant is required by law to send this notice because you own property located within 250 feet of the property subject to the proposed zoning amendment.
LAW OFFICES OF SAMUEL V.P. BANKS
To whom it may concern:
I, Bart Przyjemski, on behalf of Mia Property Acquisitions, LLC, the Contract Purchaser and Applicant concerning the property located at 740-742 N. Western Ave., Chicago, IL, authorize the Law Office of Samuel V.P. Banks, to file a zoning amendment application with the City of Chicago for that property.
Bart Przyjemski Mia Property Acquisitions, LLC
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
- Legal name of the Disclosing Party submitting th'is EDS. Include d/b/a/ if applicable:
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: f>fyLlj:he Applicant OR
2. [] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [] a legal entity with a right of control (see Section ll.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
- Business address of the Disclosing Party: Q.1^ *-{*"? i"), f^LCUA^ ^ ^
- Telephone: g <'*- -1 #2,~ W 63. Fax: 3 ia - 1 lAl:\ Email: n CoL Q ^ ^LxxLi ictuJ ■
- Name of contact person: Qte^CA-fCu . >VJi T^+^AA ~ ArTT5a«Jl2H,
- 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? ^)^-{ (f^fX^)
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
Ver. 01-01-12 Page 1 of 13
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SECTION II DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Limited liability company
1. Indicate the nature of the Disclosing Pa [ ] Person
[ ] Publicly registered business corporation [ ] Privately held business corporation [ ] Sole proprietorship [ ] General partnership [ ] Limited partnership [ ] Trust
[ ] Limited liability partnership
[ ] Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes [ ] No
[ ] Other (please specify)
2. tor legal entities, the state (or foreign country) of incorporation or organization, if applicable:
§JUk\mA
- 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? .
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[ ] Yes [ ] No j j^N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." 'NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name
Business Address
Percentage Interest in the Disclosing Party
&*\CLT ^UT-HCSCr^fc-'C
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
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Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes \^No
If yes, please identify below thename(s) of such City elected official(s) and describe such relalionship(s):
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SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and.business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.
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"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 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
A not an acceptable response.
f\TTSCLr^^[ ;
/ . ACQ rjP^C gC, Pp- ^.fWvA %%*3)ts> ex } 5 &3Q . "*
7&\ lO ( .JyOe ^^feQO !
O Pa x ^(U?y\ Co-CXoCM
(Add sheets if necessary)
[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
- COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes
[ ] No person directly or indirectly owns 10% or more of the Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
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[]Yes []No I
- 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 anyjcontroiling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies lo the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
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- The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section ll.B.l. of this EDS:
- are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded from any transactions by any federal, state or local unit of government;
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- have not, within a five-year period precedingithe date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
- are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
- have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
- have not, within a five-year period preceding; the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government. ,
- The certifications in subparts 3, 4 and 5 concern:
-
- any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
- any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
- any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect 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:
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- 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; j
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- agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
- made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
- violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
- Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in,violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offehse of bid-rigging or bid-rotating.
- Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control 'of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, Ithe Unverified List, the Entity List and the
Debarred List. !
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- The Disclosing Party understands and shall cbmply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code. j
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- If the Disclosing Party is unable lo certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Hlk
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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.
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8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
_ M/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below,'please also list the name of the City recipient.
A//A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
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1. The Disclosing Party certifies that the Disclosing Party (check one)
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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 predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates;is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City." [
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):
^
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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.
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D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ ] Yes JX(No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E. j
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.
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Does the Matter involve a City Property Sale? '
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[ ] Yes i<No j
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 j Nature of Interest
n(A-
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will
be acquired by any City official or employee. ;
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
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comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City. !
'y/^- The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves ori slaveholders described in those records:
N / At
SECTION VI CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
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NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING 1
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
l\L|A
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award ojf 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.
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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.2. above.
- The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
- If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
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B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
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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?
[ ]\es [ ] No |
If "Yes,'Vnswer the three questions below:
- HaveVou developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes \ [ ] No
- Have you fifted with the Joint Reporting Committee, the Director of the Office of Federal Contract ComplianceyPrograms, or the Equal Employment Opportunity Commission all reports due under the applicable fiWig requirements?
[]Yes \ []No
- Have you participates, in any previous contracts or subcontracts subject to the equal opportunity clause? \
[]Yes []l\o ^
If you checked "No" to question lNor 2. above, please provide an explanation:
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SECTION VII- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE ',
- The Disclosing Party understands and agrees that:
- The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
- The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on. line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
- If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the:Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
- It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained, in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS. :
- The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
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F.l. The Disclosing Party is not delinquent in the; payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City. !
(Print or type name of Disclosing Party)
(Print or type name of person signing)
(Print or type title of person signing)
Signed and sworn to before me on (date) \~~L- - { - \ 1
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 oniy an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Parly must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of die Disclosing Party listed in Section ll.B.l.a., if the Disclosing Party is a coiporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. ."Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
si f A
Page 13 of 13
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FORM OF AFFIDAVIT
Chairman, Committee on Zoning Room 304 - City Hall
Chicago, IL 60602 : To Whom It May Concern:
I, Bart Przyjemski, on behalf of Mia Property Acquisitions, LLC, understand that the Law Offices of Samuel V.P. Banks has filed a sworn affidavit identifying Mia Acquisitions, LLC as the Contract Purchaser and Elaine Miller as Owner holding interest in land subject to the proposed zoning amendment for the property identified as 740-742 N. Western Ave., Chicago, IL.
I, Bart Przyjemski, being first duly sworn under oath, depose and say that Mia Property Acquisitions, LLC, holds that interest for itself and no other person, association, or shareholder. !
ViNCENZO SERGIO OFFICIAL SEAL
Nowrv State of Illinois
My Coiiiri;ission Expires
January 03, 2016
Subscribed and Sworn to before me
j
,j ."■■'■■■ti:-
COUNTY OF COOK STATE OF ILLINOIS
I, Bart Przyjemski, being first duly sworn on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct.
Signature of Applicant
Subscribed and Swom to before me this
1 s-r day of ce 2012.
VINCENZO SERGIO OFFICIAL SEAL Notary Public, State of Illinois My Commission Expires January 03, 2016
For Office Use Only
i
Date of Introduction:
File Number:
Ward:
.'V/-. i-:-' :■.
■ . .:■ ■■
I
To whom il may concern: i
As. TrWjuJTTft" PtrA- GYh^A-o-F) M-JTLLtTJ- Xtx^XT" £p>
I. Elaine J. Miller, Owner of property located at 740-742 N. Western Ave.,
i
Chicago, IL, authorize the Law Office iof Samuel V.P. Banks to file a Zoning
Amendment application on behalf of Contract Purchaser/Applicant Mia Property
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Acquisitions, LLC with the City of Chicago for that properly.
Elaine J. Miller
t
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
I . ' ■ :
SECTION I - GENERAL INFORMATION ;
j
- LSPS-I naTjflri nf rtlR T"li cr.lncirift' Porhi cnK A,,' Bno r_ J~ J <u /I / ^--U^rtUla.
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J (?CA'g"/Jg. CP- AA-Dl .L-ElYll- f'o(L. pDc^A^ ^l^L©fL_. "TM'-ST
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this !1DS is:
1. vlfithe Applicant \^ftof^rLXM Ooj^eVU
OR .
2. [] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an-interest: , ■ : '.
OR ~~-
3. [] a legal entity with a. right of control (see "-<■»--* -«-*' *e.flm entity in
. ' which the Disclosing Party holds a right of co
- Business address of the Disclosing Party. 1 c
- Telephone- '
- Name of contact-person: A- Ajuc £><S er':cih>~- /L^-^n
j
■E: Federal 'Employer Tdeiitiiicatibn NoV'(if you have one): " /sj f^A
- Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
i
- Which City.agency or department is requesting this EDS? tryy-f EFTN '
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
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Specification # ; Lnd Contract # ; ■
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Ver. 01-01-12. Page i of 13
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SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party: I
Person [} Limited liability company
"[] Publicly registered business corporation [] Limited liability partnership
[] private-iy held business corporation [,] Joint venture
. _[] JS ole-proprietorship - ---'[t'Not-for-proftt'corp-oTati'o'n
[ ] 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:
■ *//A !
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 "Xn/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 no such members, write "ho members.". For trusts, estates or other similar entities, list below the legal titleholder(s).
.If.the entity.is-a general-partnershiprlimited partnershipr-limited liability companyy-limitedTiabinty - partnership or joint venture, list below the name and title of each general partner, managing member, manager or any o ther 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
l A- -xivjg jla^cl- L- gH'L- ■ ■ Tfl^-S -reG:
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7:5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in-a partnership or joint venture,
Page 2 of 13
interest .of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or-other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"-), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address . . Percentage Interest in the
. i nisr.lnsintr PflTtv_
SECTION'm - BUSINESS .RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party-had a "business relationship," as defined in Chapter 2-156" of the Municipal Code; with any City elected official in the 12 months before the date this EDS.is signed?
[]Yes ^No. ' '
If yes, please identify below the riame(s) of such City elected official(s) and describe such, relationship (s):
. .tJ/jAt
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED P AJR.TIES
The Disclosing P arty must disclose the name-and business address of each subcontractor, attorney, ■lobbyist-,- accountant^ consultant and any-other person ■ox'entity'wftQmtne TJtisclasiffgTarr^ or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
j
"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 (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 "ib.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 '. j
- 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 /fc^No [] No person directly or indirectly owns 10% or more of the
Disclosing Party.
' !
If "Yes," has the person entered into a court-approve'd agreement for payment of all support owed and is the person in compliance with that agreement?
■"'"["JYes ["TNT': i
- FURTHER CERTIFICATIONS ]
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1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article F')(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 lias 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 aclcnow ledges 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 1 and 3 below.
Page 4 of 13
I
I
2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.1. of this EDS:
- are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily-excluded from any transactions by any federal, state or local unit of government;
- have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged giiilty, or had a civil judgment rendered against them in connection with:
oblaining":.attem^
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;
i . .
c are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with comniitting any of the offenses set.forth in clause B.2.b. of this Section V;
- have not, within a five-year period preceding the date of this EDS, had one or. more public transactions (federal, state or local) terminated for cause or default; and
- have, not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or .found liable in a civil proceeding, or m any criminal jor civil- action, including actions ■concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government. .
3. The certifications in subparts 3, 4 and 5 concern:
- the Disclosing Party;-- ! ■
- any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in
- connection with the Matter, including but not limited to all persons or legal entities disclosed under
Section IV, "Disjjjpsuxe
- any ."Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, .or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business -entity following the ineligibility of a business entity to- do business with federal or state or local government, moluding the City; using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the tenn Affiliated Entity means aperson or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
; any responsible official of the Disclosing Party, any Contractor or any Affiliated.Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five yearshefore 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
Matterr i
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- 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 government ia.thejjnit.ed. States.of America, in that officer !s
or employee's official capacity;
- agreed or colluded with other bidders or prospective bidders, or been-a party to any-such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or' , ■
>
.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 [
a. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
«
- Neither the Disclosing Party, Affiliated Entity bi Contractor, or any of theVemployees, officials, agents or partners; is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of "720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any.similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
- Neither the Disclosing Party, nor any Affiliated Entity is listed on any of tlie following lists
. mamtained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of theU.S. Department of^ Commerce or then
'" Designated"N'a^ the Unverified List, the Entity List and the
Debarred List. :
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- The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56'(Inspector General) and 2-156 (Governmental Ethics) of the. Municipal Code.
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 explaurbelow:
' N/A
Page 6 of 13
If the letters "NA," the word "None," or no response appears on the Lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the'.Disclosing Party's knowledge after reasonable inquiry, the following is a . complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this ED.S. an employee, or elected or appointed official, of the City of Chicago (if none, indicate with 'WA" or "none").
--f-
C. CERTIFICATION O'F STATUS AS FINANCIAL INSTITUTION '
- The Disclosing Party c6rtifies that the Disclosing Party (check one)
[] is J^fis not'
a "financial institu^ - --
- 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 defmedin Chapter 2-32 of the Municipal Code. Weunderstand that becoming apredatory lender or becoming ah affiliate of a predatory lender may result in the Iciss 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 iri 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):
^ _jl : MIA,
Page 7 of 13
Tf the letters "N A," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTBRESf IN CITY BUSINESS
i
Any words or terms that ars'defined in Chapter 2-156 of the Municipal Code have the same
meanings-when used-in-this-Pavt ©-.-- 7 - ;:
, 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?
[] Yes . Jp^Ko j
NOTE: If you checked "Yes" to Item D.l.,.proceed-td ItemsD.2. and D.3. If yon checked "No" to
Item -D.l., proceed to Part E. ' j '
2. Unless sold pursuant to a process of competitive bidding,' or otherwise permitted, no City elected official orempioyee shall have a financial interest in his ot 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")1. Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D
i i
Does the Matter involve a City Property Sale?' ' []Yes ^No
. J .If you.checked.'JY-es.-to Item D.L,- provide the names and-business-addresses- of-the Gity officials or. employees having such interest and identify the nature of such interest:
Name Business Address ! Nature of Interest
4. The Disclosing P arty further certifies that no prohibited financial interest in the Matter will" be acquired by any City official or employee. '
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
.' Please check either 1'. or 2. below. If the Disclosing Party checks 2.,-the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13
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comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City. / /]
HjlX
The Disclosing Party verifies that the Disclosing Party has searched any and all records of
the Disclosing Party and any and all predecessor entities regarding records of investments or profits from, slavery or slaveholder insurance policies dining 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 hasi foundino 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:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter Is-federaUy funded, complete this Section Vl. If'the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City . and proceeds of debt obligations of the City are not federal funding.
A.'.CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: .(Add sheets if necessary): . !
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear,-it will he 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.) i
2. The Disclosing Party'has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to inflnence an officer ot employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a-member of Congress, in connection with' the'award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative-agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
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 tr 6 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 lis not an organization, described in section 501(c)(4) of the Internal Revenue Code of 1986; or (iij 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".
iiosmg rarty is me appucant, the Disclosing party must ootain cenmcanons equai in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY ' .
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information^vith their bids or in writing at the outset of negotiations. .
M||A-
Is the Disclosing Party the Applicant?
[]Yes . []No If "Yes,"'answer the three questions below:
- Have y\m-developed and do you have on file affirmative action-programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.) . j _ ,
[-3 Yes \~ []"No :j
- Have you fileo\witIi the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Qpportunity Commission all reports due
under the app lie ab le filing requirements? ! j
[]Yfes" ' \UNo
- Have you participated ifyany-previous contracts or subcontracts subject to the equal opportunity clause? '
[ ] Yes . [ ] Ho'
If you checked "No" to question 1. 6rV above, please provide an explanation
Page"!
0 of 13
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SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that: ! . .'
- The certifications, disclosures, and acknowledgments contained in this EDS will-become part of any contract of 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 talcing other action with respect to the Matter!' The Disclos ing Party understands that it must comply with all statutea-, ordinances, and regidations on which this" EDS is based.
- The.City's Governmental Ethics and CampaignFihancing 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 ^ at www.cityofchioago.orp;/Ethton, and may also be obtained from the City's Board-of Ethics, 740 K.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances;
i
- If the City .determines that any information provided in this EDS is false, incompleteor inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void ot ' 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 participated other transactions with,the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages. ■
- It is the City's policy to malce-this document available to the public on its Internet site and/or upon request. Some or all of the information provided onthis.EDS and any attachments to this EDS may be
; made -available to the public" oh the 'Internet, in response to a "Freedom of hVformation Act request^ or""'"' otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible-rights or claims which it may. have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify'the accuracy of any information submitted in this EDS.
- The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eUgibillty must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 |of the Municipal Code.
I ■The Disclosing Party represents and warrants that: I
Page ll of 13
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CITY OF CHICAGO . ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
i -.
This Appendix is to be completed only by'(a) the Applicant, and (b) any legfll.enury which has a direct ownership interest in the Applicant exceeding 7.5 percent It is hot 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 Parmer thereof currently has a "familial rdationship'' with any. elected city ofBcial-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, mqtlier-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) alLexecuuye officers of.the Disclosing Party listed'in Section E.B. 1 .'a., if the .
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general ^
partnership; all general partners and Urnited partners'of the Disclosing Party, if the Disclosing Party is a Ihrnted
.partnership; all managers;, managing members and members of the Disclosing Party, 'if the Disclosing Party is a .
limited liability company; (2) all principal officers- of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating, officer, executive director, chief financial officer, treasurer or secretary-of a legal entity or any person
exercising similar authority. .
D.oes.the Disclosmg-Party-or-any'-'^
have a "familial relationship" with an elected city official or department head?
[ j Yes jf^JNo
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise' nature of such familial relationship. .
'- , - I ■' . '
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Page 13 of 13
I
SECTION VII -\ ACKNOWLEDGMENTS, CONTRACT INCORPORATION, " COMPLIANCE, IffiNALTBiS, DISCLOSURE
The Disclosing Party Understands and agrees that: ' .'
- The certifications, disclosures, and acknowledgments contained -in this EDS will-become part of any
contract of other agreementhetween the Applicant and the City in connection with the Matter, whether
procurement, City assistance, hr-other City action, and-are material inducementsto[^Oj^s-&7LWi^.qn
" " of any contract or takmg other ^"on with respect to the Matter. The Disclosing Party understands that it must comply with all statutes-, ordinances, and regulaticfns on which this''EDS is based.
- .The. City's Governmental Ethics anli Campaign-Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain dut«s and obligations on persons.or entities seeking City contracts, work, business, or transactions. The full wxt of these ordinances and a training program is available on line at www.cityofchioago.org/Bthics. and may also be obtained from the City's Baard-fff Ethics, 740 N.
Sedgwick St, Suite 500, Chicago, EL 60610, (31&) 744-9660. The Disclosing Party must comply fully with the applicable ordinances; \
- If the City.determines'that any information provided in this EDS.is false, incomplete" or inaccurate, any contract or other agreement in connection with whioh it is 'submitted may be rescinded or be void ot ■ voidable, and the City may pursue any remedies under the\pontract or agreement (if not rescinded or void), at law, or in equity, mcluding temhiating the Disclosing Party's participation in the Matter arvd/or declining to allow the Disclosing Party to participate in omertoansactions 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. V
- It is the City's policy to makethis document available to the public on its Internet site and/or upon request. Some or all of the information provided on this.EDS and anyNattachm'ents to this EDS mayTae
-■made'available to'the public'oh the'mt'erhet,'in response to a Freedom o^^ Actrequest, 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 pNiblic 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 ch'aWes, 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 Artfcle 1 of Chapter 1-23 of the Municipal' Code (imposing PERMANENT INELIGIBDLITY fot ce\£ain specified offenses), the information provided herein regarding eUgibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
- The Disclosing Party represents and warrants that:
Page 11 of 13
F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the'lllmois Department .of Revenue,- nor are the Disclosing Party pr.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 willnot
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. Sj. General Services. Adminjstration,
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 tp those in F.l. and F.-.2. above and will not, without the prior written consent of the ■City, use.any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications
NOTE: If the Disclosing Party.cannot certify as to any.of the items in F.L, F.2. or F.3" above, an explanatory statement must be attached.to this EDS.
CERTIFICATION
Under penalty of perjury.'the person signing below: j(l) warrants that he/she is' authorized to execute this EDS and-Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants .that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and.complete as of the-.date furnished to the City.
(Print or type name of Disclosing Party)
(Print or type name of person signing)
(Print or,type title of pdrson signing)
Signed and sworn to before me. on (date) /2^^L#>2~-,
at C na /C County, T\JUlt^6i j (statel.
l£* Notary.Public.
-Commission expires: ^Jfyjf^
Page'12 of 13
SECTION VII -\ ACKNOWLEDGMENTS, CONTRACT INCORPORATION, C0MPLIANCE,\ENALTD2S, DISCLOSURE
The Disc Losing Party understands and agrees that:
- The certifications, disclosures, and acknowledgments contained in this EDS will-become part of any contract of other agreementhetween the Applicant and the City in connection with' the Matter, whether
procurement, City assistance, or-other City action, and are material inducements to[Jdie City's ex^ .
■of any co'ntract"or takhig other ^"on with respect to the Matter. The Disclosing Party understands that
it must comply with all statutes-, ordinances, andregiuations on which this" EDS is based.
- .The. City's Governmental Ethics anti Campaign-Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain dut«s 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.cityofchioago.org/Ethios. and may also be obtained from the City's Bdard of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, EL 60610, (31*2) 744-9660. The Disclosing Party must comply fully with the applicable ordinances, \
- If the City^etermmesthat 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 ot 1
- voidable, and the City may pursue any remedies under the\contract or agreement (if not rescinded ox
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 otherfransactions 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. ' , V
- It is the City's policy to make this document available to the pubac on its Internet site and/or upon
- request. Some or all of the information provided on this.EDS and anyattachments to this EDS may be
made available to "the public* oh the mfe'rhet", in response to a Freedom os^formation Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may. have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS. \ "
- The information provided in this EDS must be kept current. In the event of ch'aWes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter, tf the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY fot c&^ain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
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