Office of the City Clerk - Record #: O2013-4978

Record #:

O2013-4978

Type:

Ordinance

Status:

Passed

Intro date:

6/26/2013

Current Controlling Legislative Body:

Committee on Finance

Final action:

7/24/2013

Title:

Loan agreement with Senior Suites Chicago Norwood Park, LLC for rehabilitation and construction of addition to building at 5700 N Harlem Ave

Sponsors:

Emanuel, Rahm

Topic:

AGREEMENTS - Loan & Security

Attachments:

1. O2013-4978.pdf

Date	Journal Page Number	Action By	Action	Result	Action Details	Meeting Details	Captions
8/15/2013		Office of the Mayor	Signed by Mayor		Action details	Meeting details	Not available
7/24/2013	57590	City Council	Passed	Pass	Action details	Meeting details	Not available
7/19/2013		Committee on Finance	Recommended to Pass	Pass	Action details	Meeting details	Not available
6/26/2013	56016	City Council	Referred		Action details	Meeting details	Not available

S:\SHARED\Finance\Senior Suites Norwood Pk\Ordinance\ordinance 4.doc

ORDINANCE

WHEREAS, the City of Chicago (the "City"), a home rule unit of government under Section 6(a), Article VII of the 1970 Constitution of the State of Illinois, has heretofore found and does hereby find that there exists within the City a serious shortage of decent, safe and sanitary rental housing available to persons of low and moderate income; and

WHEREAS, the City has determined that the continuance of a shortage of affordable rental housing is harmful to the health, prosperity, economic stability and general welfare of the City; and

WHEREAS, Senior Suites Chicago Norwood Park, LLC, is an Illinois limited liability company (the "Borrower"), of which Senior Suites Chicago Corporation, an Illinois corporation, is the sole member; and

WHEREAS, the City has certain funds available from a variety of funding sources ("Multi-Family Program Funds") to make loans and grants for the development of multi-family residential housing to increase the number of families served with decent, safe, sanitary and affordable housing and to expand the long-term supply of affordable housing, and such Multi-Family Program Funds are administered by DHED; and

WHEREAS, DHED has preliminarily reviewed and approved the making of a loan to the Borrower in an amount not to exceed $3,400,000 (the "Loan"), to be funded from Multi-Family Program Funds pursuant to the terms and conditions set forth in Exhibit A attached hereto and made a part hereof; now, therefore,

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

SECTION 1. The above recitals are expressly incorporated in and made a part of this ordinance as though fully set forth herein.

SECTION 2. Upon the approval and availability of the Additional Financing as shown in Exhibit A hereto, the Commissioner of DHED (the "Commissioner") and a designee of the Commissioner (collectively, the "Authorized Officer") are each hereby authorized, subject to approval by the Corporation Counsel, to enter into and execute such agreements and instruments, and perform any and all acts as shall be necessary or advisable in connection with the implementation of the Loan. The Authorized Officer is hereby authorized, subject to the approval of the Corporation Counsel, to negotiate any and all terms and provisions in connection with the Loan which do not substantially modify the terms described in Exhibit A hereto. Upon the execution and receipt of proper documentation, the Authorized Officer is hereby authorized to disburse the proceeds of the Loan to the Borrower.

SECTION 3. Section 2-45-110 of the Municipal Code of Chicago shall not apply to the Project (as defined in Exhibit A) or the Property (as defined in Exhibit A).

SECTION 4. If any provision of this ordinance shall be held to be invalid or unenforceable for any reason, the invalidity or unenforceability of such provision shall not affect any of the other provisions of this ordinance.

SECTION 5. This ordinance shall take effect immediately upon its passage and approval.

EXHIBIT A

TERMS AND CONDITIONS OF THE LOAN

BORROWER: Senior Suites Chicago Norwood Park, LLC, an Illinois limited liability company (the

"Borrower"), of which Senior Suites Chicago Corporation, an Illinois corporation, is the sole member (the "Member"), and others to be hereafter selected as additional members

PROJECT: Rehabilitation of and construction of an addition to a building located at 5700 North

Harlem Avenue, Chicago, Illinois (the "Property") and of approximately 84 dwelling units contained therein as studio, one-, and two-bedroom units for low- and moderate-income senior citizens and up to 65 on-site parking spaces

LOAN:

Source: Amount: Term: Interest:

Security:

Multi-Family Program Funds Not to exceed $3,400,000 Not to exceed 32 years

Not to exceed three percent per annum, or another rate acceptable to the Authorized Officer Non-recourse loan; third mortgage on the Property, or other security acceptable to the Authorized Officer

ADDITIONAL FINANCING:

Amount: Not to exceed $725,000

Term: Not to exceed 32 years

Source: BMO Harris Bank N.A., or another entity acceptable to the

Authorized Officer ("Harris") Interest: Not to exceed 12 percent per annum Security: Recourse loan during construction; Non-recourse loan at

conversion to permanent loan phase; first mortgage on the

Property and other security acceptable to the Authorized

Officer

2. Low-Income Housing Tax Credit

("LIHTC") and Historic Rehabilitation Tax Credit ("HRTC")

Proceeds: Approximately $17,789,417, the receipt of some or all of which may be bridged by a recourse loan from Harris to the Borrower, which loan will: have a term not to exceed 24 months; bear interest at a variable rate not to exceed 12 percent; and will be secured by a second mortgage on the Property, assignment of membership interests in the Borrower and other security acceptable to the Authorized Officer

Source: To be derived from the syndication of (a) $1,743,000 LIHTC allocation by the Illinois Housing Development Authority (generating approximately $16,295,420 of proceeds) and (b)

approximately $1,598,018 HRTC (generating approximately $1,493,997 of proceeds)

Amount: Approximately $640,000

Source: Federal Home Loan Bank Affordable Housing Program grant

Amount: Approximately $239,080

Source: Illinois Department of Commerce and Economic Opportunity grant

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:

Senior Suites Chicago Norwood Park, LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[*] the Applicant

[] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest:

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

which the Disclosing Party holds a right of control:

111 E. Wacker Dr., Suite 2200

B. Business address of the Disclosing Party:

Chicago, Illinois 60601

Telephone: ³¹²"⁶⁷³"⁴³³³ Fax: ³¹²-⁶⁷³-⁴⁴⁷⁶ Email: rgawronski®_Senionif estyie.com
Name of contact person: ^Robert Ga^onski
Federal Employer Identification No. (if you have one): \

F. Brief description of contract, transaction or other undertaking (re'ferred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

HOME funding for 5700 N. Harlem Avenue

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

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

Specification # ^Not ^aPP^licable and Contract # ^Wot ^aPP^licable

Ver. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

Person

Publicly registered business corporation

Privately held business corporation

Sole proprietorship

General partnership

Limited partnership

Trust

P] Limited liability company

[ ] Limited liability partnership

[ ] Joint venture

[ ] Not-for-profit corporation

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

[]Yes []No [ ] Other (please specify)

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

Illinois

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

[ ] Yes [ ] No [*] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, 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

Senior Suites Chicago Corporation its sole member *

* At closing, it is anticipated that the managing member will be the to-be-formed Senior Suites Chicago Norwood Park JV, LLC, a joint venture between Senior Suites Chicago Corporation and UNO Senior Housing Development Corporation.

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

Page 2 of 13

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

Name Business Address Percentage Interest in the

Disclosing Party

Senior Suites Chicago Corporation 100% **

~~Ill E.~~ -W~~duktii Di . , Suile 2200~~

Chicago, Illinois 60601

** At closing, it is anticipated that Boston Capital Direct Placement(Templar House, Don Road, sF! Helier, Jersey JE1 2TR, Channel Islands, Great Britain) will acquire up to 99.99% of the applicant's membership interests and Senior Suites Chicago Corporation will retain its controlling interests as the controlling member of the applicant's managing member.

SECTION III -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ ] Yes [*] No

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

Not applicable

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

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

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

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

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

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

not an acceptable response.

Daspin & Aument, LLP; 227 W. Monroe K2S00; Chicago IL 60606; Attorney; $25,000 (est.) Katten Muchin Rosenman LLP; 525 W. Monroe Street; Chicago IL 60661; Attorney; $90,000 (est.) NORR Illinois; 325 H. LaSalle, (1700; Chicago IL 60610; Architect; $500,000 (est.)

MacRostie historic Advisors LLC; 53 W. Jackson H1357, Chicago 60604; Historic Consultant; $52,000 (estTT

~>7aT^^_C6nsTriIcTionn^TnpahYTT: LTTT- 929 WT^aaTSsT"TTO"cago^_1S~0W77G^e"faT~Contractor; $14 , 910 , lOOTest^-."]

Plante Moran; 225 W. Washington Street Suite 2700, Chicago 60606; Accountant; $16,000 (est.)

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

Disclosing Party.

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

[]Yes []No

FURTHER CERTIFICATIONS

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 of charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

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

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

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

Page 5 of 13

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

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

Neither the Disclosing 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 of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Nou applicable

Page 6 of 13

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

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

none

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

none

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [X] is not

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

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

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

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

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[]Yes [^x]No

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

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

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

j 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

None

(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.I. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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?

[^x] Yes [ ] No

If "Yes," answer the three questions below:

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

[ ] Yes [*] No

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

[ ] Yes [*) No

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

[JYes pT.No

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

The Applicant is a newly created entity which has not previously participated in other, federally funded matters. But in tenets" to comply witlT aiT'ot the^-applicable federal regulations associated with the" federal funding to be received.

Page 10 of 13

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

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain ditties 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.citvolchicaao.orH/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 faisc statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

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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 Parly is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hived 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. 1., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penally of perjury, the person signing below: (1) warrants that he/she is authorized to execute 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.

SENIOR SUITES CHICAGO NORWOOD PARK, LLC

3y: SENIOR SUITES CHICAGO CORPORATION, its sole member

(Print or type name of Disclosing Party)

(Sigi/here)

By:

Robert Gawronaki

(Print or type name of person signing)

OFFICIAL SEAL DAPHNE WILLIAMS

Assistant Treasurer

(Print or type title of person signing)

Sigapd and sworn to before me on (date) / [ ^J

at _ County, ZX^b/lcLo (state).

Notary Public.

Commission expires:

Page 12 of 13

CITY OF CHJCAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

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

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

[]Yes [^x]No

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION 1 ~ GENERAL INFORMATION

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

Senior Suites.Chicago Corporation

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

[^x] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: senior suites Chicago Norwood Park, llc

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:

111 E. Wacker, Suite 2200

B. Business address of the Disclosing Party:

Chicago, Illinois 606 01

C Telephone^- ^312-673-4333 Fax' ³¹²"^673-4476 Email" ^r9^awronski®^seni^oriif^estyi^e-^com

Name of contact person: ^Robert G^a"ronski
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):

HOME funding for 5700 N. Harlem Avenue

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

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

Specification # ^Not ^aPP^licable and Contract # ^Not ^aPP^licable

Ver. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

Indicate the nature of the Disclosing Party:

[ ] Person

| ] Publicly registered business corporation

[^x] Privately held business corporation

[ ] Sole proprietorship

[ ] General partnership

[ ] Limited partnership

[ 1 Trust

[ ] Limited liability company

[ ] Limited liability partnership

[ ] Joint venture

[ ] Not-for-profit corporation

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

[]Yes []No [ ] Other (please specify)

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

Illinois

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?

[ j Yes [ ] No [*] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

Name

William B. Kaplan James B KTutznick Jerrold Ii. Fromm

Robert Gawronski Stephen J. Levy

Israel Levy

Title

President. Treasurer, Director

"Vice President, Director Secretary

Assistant Treasurer Assistant Secretary

Page 2 of 13

Name Business Address Percentage Interest in the

Disclosing Party

William B. Kaplan; I¹¹ ^E■ Wacker Suite 2200, Chicago, IL 60601; 60%

"James B. TUutznTck^ IiTe^-Wacker Suite~2200, Chicago, 1I7~60601; 30% Israel Levy, 111 E Wacker Suite 2200, Chicago, IL; 10%

SECTION 111 -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-1 56 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes [*] No

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

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

"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 "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

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

COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

Disclosing Party.

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

[ ] Yes [ ] No

FURTHER CERTIFICATIONS

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

Page 4 of 13

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

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

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

Page 5 of 13

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

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

Page 6 of 13

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

N/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 lo the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is (*] is not

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

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

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

In accordance with Section 2-156-110 of the Municipal Code: Docs 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 [*] No

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

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

Does the Matter involve a City Property Sale?

[]Yes []No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

_^x 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section 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

none

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

Page 9 of 13

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[ ] Yes [^XJ No

If "Yes," answer the three questions below:

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

[]Ycs []No

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

[ ] Yes [ ] No

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

[ ] Yes [ ] No

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

Page 10 of 13

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

The Disclosing Parly 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.citvofchicaao.orR/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 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:

Page 11 of 13

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

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. 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 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.

SliNIOR SUITES CHICAGO CORPORATION

(Print or type name of Disclosing Party)

By:

Sjgn here)

Robert Gawronski

(Print or type name of person signing)

Assistant Treasurer

(Print or type title of person signing)

</Wn

Detore me on (date; J I ~* (_ _

County, ^Ih/tPl^ (state).

Sig^^m^sworn to before mejm/date)

ftljf2fLr\J ^JJuyf^^ Notary Publi Commission expires:

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

[ ] Yes . [^x] No

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION 1 - GENERAL INFORMATION

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

duo Senior/, Qe»je-LopMe*jr o^PflfsfrfrofO

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [ ] the Applicant

OR ^ftr cVccR) n» -

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

Applicant in which the Disclosing Party holds an interest: jj^c MSOft- 6^{*-'LX&& CtV£CA<jQ

OR N01.va>ooO f>fW,\C_t LLC-

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: ^VS'H V»J uJAr6t-V CpO 'oH/A, Sfc 2S
Telephone: MaX-<^S01 Fax: 1?3.-QQ"t1 Email: 4^1 Tfj) KmQ-QAJ<-C»/c.0¥ZC^
Name of contact person:
Federal Employer Identification No. (if you have one): ■. __ __ __ ^
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

G. Which City agency or department is requesting this EDS? QfcrPf Qp HOQTXy. fcHO ccOO^d-

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

Specification # and Contract #

Ver. 01-01-12

Page 1 of 13

SECTION H - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

[ ] Person [ ] Limited liability company

[] Publicly registered business corporation [] Limited liability partnership

^ Privately held business corporation [ ] Joint venture

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

t ] 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:

tllj:ooj:s

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:

Name Title

SEg attachexH-Mg.LT & 9- Mo let*.^ bMrxrce^ mix

Page 2 of 13

Name Business Address Percentage Interest in the

Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[] Yes

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

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.

C<>T . df /_fO0O~

(Add sheets if necessary)

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

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

[]Yes

[ ] No f!&No person directly or indirectly owns 10% or more of the

V 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

The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section Il.B. 1. of this EDS:

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

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

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

Page 5 of 13

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

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

Page 6 of 13

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.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION 1. The Disclosing Party certifies that the Disclosing Party (check one)

[]is

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:

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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? j

□ Yes

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

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

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

Page 9 of 13

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[]Yes

If "Yes," answer the three questions below:

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

[ ] Yes [ ] No

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

[ ] Yes [ ] No

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

[ ] Yes [ ] No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

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

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

If the 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 Parry's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F. I. 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. B.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

vjm6 teniae. rVMVPur^ oeoLua^ .

(Print c^ty^^^^of Disclosing Party)

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

Signedand sworn to before me on (date) & ~~ ¥ " k~ County, ~E-Lrl~ - (state).

'IsiOjrujLe-*- ~~7JLucl/x. Notary Public.

Commission expires:_

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

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

[ ]Yes

Page 13 of 13

Exhibit 1

HOME funding for 5700 N. Harlem Ave.

Exhibit 2

UNO Senior Housing Development Corporation Board of Directors

President juan Rangel

954 W. Washington Blvd. Ste. 3S Chicago, Illinois 60607

Secretary Andrew Alt

954 W. Washington Blvd. Ste 3S Chicago, Illinois 60607

Exhibit #3

While the Disclosing Party is able to certify to all statements in Part B, in the interests of full disclosure, please note that the United Neighborhood Organization of Chicago, the 100% Owner of all shares of the Disclosing Party, is in receipt of a letter from the Illinois Department of Commerce and Economic Opportunity ("DCEO") dated April 25, 2013 relating to State Grant Numbers 10,203024,10-203037 and 12-203291 (collectively, the "State Grants") in which DCEO declared a temporary suspension of payments under the State Grants pending the receipt of grant audits and various other deliverables. As of this date, no formal action other than the aforesaid letter has been taken by DCEO to terminate the State Grants or otherwise bar the United Neighborhood Organization of Chicago from doing business with the State.

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

OR TrtfrT fcXfCcT^-¹^

])^a legal entity'noldiirg a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: StulO/L SUt-f^ C rr S L*Ho Q

OR HJofljpuoC <»Art,K, LLC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party:
Telephone:^ z\ 433--Lp3Q1 Fax:fcl2^ 432-0011 Email: QQ.lT g)^-!)^.^
Name of contact person:
Federal Employer Identification No. (if you have one): _.
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

aeg ft«TAifreo ex.ttvq>Er ^ )

Which City agency or department is requesting this EDS? QGPT. OF HtMsDVftj Q<ufl cxQaxV^C,

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-n

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

[ ] Person [ ] Limited liability company

[ ] Publicly registered business corporation [ ] Limited liability partnership

[ ] Privately held business corporation [ ] Joint venture

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

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

[ ] Limited partnership ^.Yes [ ] No

[ ] Trust [ ] Other (please specify)

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

xutXMor<s

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 Vl^/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

Name _ Title _

fr< i eatX4C( # 3i no Lg~(fm_ trAjrcrtes rVLc

Page 2 of 13

Name Business Address Percentage Interest in the

. Disclosing Party

HQU^ 

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

□ Yes

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

Page 3 of 13

Name (indicate whether Business retained or anticipated Address to be retained)

Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)

Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.

(Add sheets if necessary)

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

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

[]Yes

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

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

[ ] Yes [ ] No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("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 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

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

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

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

Page 5 of 13

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

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

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

Page 6 of 13

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

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

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION 1. The Disclosing Party certifies that the Disclosing Party (check one)

[]is

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:

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 th* meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[ ] Yes Wno

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

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

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

Page 9 of 13

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

□ Yes

If "Yes," answer the three questions below:

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

[ ] Yes [ ] No

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

[ ] Yes [ ] No

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

[]Yes []No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofcbicago.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 I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.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

uioT-r^Q N^iGrVaofchoop onXs^MPZAnnro

(Print or type name of Disclo/ing Party)

(Sign here) ^ V (Print or type name of person signing)

ceo

(Print or type title of person signing)

fstateL

Signed and sworn to before me on (date)

at Ljity k' County, 'Ztil- L ■

Notary Public.

Commission expires: "3 "JLQ / 6

OFRC&SEM. QftCt&AFBMLES

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFTOAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

[ ]Yes

Page 13 of 13

Exhibit 1

HOME funding for 5700 N. Harlem Ave.

The UraiSed Neighborhood Organization

954 W. Washington Blvd., 3rd Fl, Chicago. Illinois 60607

312.432.6301 tel 312.432.0077 fax

uno-onllne.org

EXHIBIT 2

UNO Board Members

Chairman - Martin Cabrera Jr. - Founder and CEO, Cabrera Capital Markets LLC [see-attached bio)

Joseph de Lopez - Former Winnetka Police Superintendent and VP of Voorhees Associates
Pastor Freddy Santiago - Iglesia Rebano Church
Professor Peter Skerry - Department of Political Science at Boston College and Nonresident Senior Fellow at the Brookings Institution
Rodolfo Benitez - UNO parent
Mariana Chavez - UNO parent

UNO Corporate Executive Officers

Juan Range!, Chief Executive Officer
Phillip Mullins, Chief Strategy Officer
Kathy Mclntyre, Chief Financial Officer

Exhibit #3

While the Disclosing Party is able to certify to all statements in Part B, in the interests of full disclosure, please note that the United Neighborhood Organization of Chicago is in receipt of a letter from the Illinois Department of Commerce and Economic Opportunity ("DCEO") dated April 25, 2013 relating to State Grant Numbers 10,203024,10-203037 and 12-203291 (collectively, the "State Grants") in which DCEO declared a temporary suspension of payments under the State Grants pending the receipt of grant audits and various other deliverables. As of this date, no formal action other than the aforesaid letter has been taken by DCEO to terminate the State Grants or otherwise bar the United Neighborhood Organization of Chicago from doing business with the State.

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

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

fia.chh C*ft^ D)rtot P( MMen-h.fr Urn tied P*rtneuh)p

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[J^eApp.ica,,, ^_tiflM^
1. f-fa legal entity holdi&g- a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an intcrest^A/oK SUiitS ChtCfldO NQTUJVvd ffoffc,

OR ¹⁷ Lit

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: f)tl6 P)n(ivr\ Pl&Ct Aurfc >I&G

fcoJ-hn AAA 07-IO&

Telephoned/Thl-HFax: bl7-Q>lY~ 0 fff Email: (rchmfygb^M CtLfM L
Name of contact person: (hfChUU C^hgmj^^J
Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

\\~QUB. -hhiuncj -hr 51 oo /V - {tAHvfy Avtnuc

Which City agency or department is requesting this EDS?_

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

Specification # Jsjoj Ajtjpjl Cttbfa and Contract # /V't 0ypltt«.bl*C

Ver. 01-01-12

Page 1 of 13

SECTION II - jOISCLOSUaS p.F'QV7HUtfl9I* XrtTSpJiiSTS A. NATURE 07 TH5 DISCLOSING PARTY

I - Indicate the nature of the Disclosing [] Person

i ] Publicly registered business corporation [ J Privately held business corporation T ] Sole proprietorship [ ] General partnership \J[ Limited partnership [j Trust

[; Limited liability company i j Limited IiaWbty partnership .{1 Joint venture £ j Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

[ ] Yes [ ] No

j ] Other (please specify)

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

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

i ] Yes [yfNo [ ] N/A

B. IF TEE DISCLOSttJG PARTY IS A LBOAL ENTITY:

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

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

Name Title

jj&pxMt frUiftjS/Ut- 6?

2. Pleass 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

Name .Business Address Percentage Interest in the

Disclosing Party

rtwuh hivaimtiir fhlditiyjnr' \ 7 tot** Plxtt Ub- C*7'A

^) Suite UW

aucTioj? m-simzmss jraLATioNsmrs with cmr jklxctss osaiciALS

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

J Yes No

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

SECTION IY _ DiSCLCSUjaB OJ 3U:3CONTIL4CTC-ES AND OTHB3S I<3TAnf3i> ^ASTISS

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and cny other person or entity whom the Disclosing Parry 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 fess 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 ot entity who undertakes to influence any legislative or administrative action on benalf of any person or entity other than: (1) £ not-for-profit entity, on an unpaid basis, or (2) kmiBelf. "Lobbyist" also means any person or entity any part of whose duties as aa employee of another includes undertaking to influence any legislative or adrmnisiraiive 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.

?age3of 13

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

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

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

not an acceptable response.

(Add sheets If necessary)

[i/ciieck here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

section y - cm'fmcA'notiS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[lYes

i ] 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?

[ I Yes rjNo

3. FURTHER CERTIFICATIONS

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

J?sse4of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 113.1. 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;
hsve 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; malting 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 notions 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 sntitiss disclosed under Section IV, "Disclosure of Subcontractors snd Other Retained Parties");

any "Affiliated Entity" (meaning -3 person or entity that, directly or indirectly: controls the Disctosma 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 ramify members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligfoffity of a business entity to do business with federal or state or local government, including the City, ;?sing substantially the same management, ownership, or principals as the ineligible entity); w:& respect to Contractors, the terra Affiliated Entity means a penon or entity that directly or indirectly controls the Contractor, is controllec.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 AffiliRted Entity or any other official agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to she direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (coUectivsly ^Agonts").

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, duriag the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or on Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

bribed or attempted io bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a pubb'c officer or employee of the City, the State of Illinois, or any agency of thB federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or' prospective bidders, in restraint of .freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or

a. 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 gs 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 of720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Conirol 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. Thd 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 explain below:

Page 5 of 13

If the letters "NA," the word "None," or no response appsars 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 ths 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if aoae, indicate with "N/A" or "none").

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during he 12-montfc period preceding the execution date of this EDS, to en smployee, or sleeted or appointed official, of the City of Chicago. For purposes of this statement, a "gift" dots 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 Tvith "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is &,] is not

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

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

"We are not and -will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code, We further piedge that noae ofou! affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. V/e understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in she loss of the privilege of doiiig business with the City."

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

Pegs 7 of 13

If the tetters "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 Dl CITY BUSINESS

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

In accordance with Section 2-156-i 10 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the "Matter? /

[ ] Yes kj4lo

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

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

Does me Matter involve a City Property Sale?

HYes -]No

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

Name Business Address Nature of Interest

4. The Disclosing Party farther certifies that ao prohibited financial interest in the Matter will be acquired by any City official or smployee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSEN335

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

Page 8 of 13

comply with ihese disclosure requirements may ma!:e any contract entered into with the City in conne,ction with the Matter voidable by the City.

I. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing P-oty 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 io 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

SECTiOR VI - CERTIFICATIONS TOR I?£l>E2ALi.¥ .TTUrtOSC-

NOTTS:.If tfea Matte/ is fatlsrairy fuausiL sorcplete this Section VL U iaa Matter \s apt fadi!rw3y feadsc, 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

(If no explanation appecrs or begins on the Imss above, or if the letters "NA" or if the word "Nous" 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 influmice 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 nidrnbej of Congress, in connection with the award of any federally funded contract, malting any federally funded grant or loan, entering into any cooperative agreement, or to extend, coatinue, renew, amend, or modify cay federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification at the end of etch calendar quarter in which there occurs any event that materially affects i\e 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 1985; or (ii) it Is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.I. through A.4. abovs from all subcontractors before is awards any subcontract and the Disclosing Party must maintain all such subcontractors' certificatiocs for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

f ¹ Yes

If "Yes/" answer the three questions below:

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

FjYes [jNo

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

iiYss HNo

Have you participated :n any previous contracts or subcontracts subject tc the equal opportunity clause?

H Yes []No

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

Page 10 -J 13

SECTION Y2I- AClKrtOm20GJr33NXS» CONTRACT JNCO^OfexTXON, CCuVlFLIilNCE, FSNALTI3S, S'iSCLGSO'OE

The Disclosing Party understands and agrees that:

The certifications, disclosures, and acknowledgments contained h- 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, o^linances, and regulations on which this EDS is besed.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-154 of the Municipal Code, impose certain duties and obligations on persons or entities 3eeking City contracts, work, busiasss, or transactions. The full text of these ordinances and a trsining program is available on line at www.citvorchicago.orE/Bthics. and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 5C510, (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 decbning 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.

0. It is the City's policy to *nake this document available to ihe public on its Internet site and/or upon request. Some or all of ths information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response- to e 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 BD3 must be kept current. In the event of changes, the Disclosing Party must supplement this 5DS up in the time the City takes action on the Matter. If the Metier is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requirea. KOTjS: With respect to Matters subject to Article I of Chapter 1-23 of the Mmaicipal Code (imposing JFSIlMAHtSirTr Xfl27-4GI»ii8JTY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a ionger period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

PageII of 13

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

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

Jforfr/? Uprhrf b)rtOk PI a foment, A Umiietf P^tHhip

(Print or type name of person signing)

(Print or type title of person signing)

Signed and sworn to before me on

(state).

(date) A 7 $9,20/3

at JqffpllL. County, /ftfl

Page 12 of 13

CITY OF CHICAGO jSCOSIOMaC £i»GLGSUKB SXATZMEiSrr ARD AmOAViT

FAiYfilXAL HKLATiONSIiuPS WTJGFf FXISCTiEO CXTV 0PRCZAX8 AKD Bl^ARTivGSNX HB&DS

Tnls Apff«cu"ii u to I?c eaj^iiie^ >rdy by (a) iha A^pHccai, £i»o (b) "*«y^;-fp! sniliy fMi'-'b ass a Sirect owawiarjs Sateroat ?c sis ApulteBs.i gr.3BS&ng 73 ?«FsnBi. It net *o ae eom;K3%3«3 &7 cay lags! ar.«iiy ■w&SsSi ua» ao!y fa-Sires:: orjajtublp iateL-estts His A$jj>!!s3af.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or aay Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "fatuilial relationship" exists if, as of the date this EDS is signed, the Disclosing Patty or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, rhs 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 cephew, graodpareti; grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather cr stepmother, stepson or sttpdaughtar, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section H.B.1 a, if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general rMrtnership; ail general partners and lirnrted 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 Pariy is a Limited Eabiliry company, (2) ril principel officers of the Disclosing Party; and (3) any person having more than a 1J5 percent ownership interest in the Disclosing Party. "Principal officers" means the pi-ssident, chief operating officer, executive director, chief financial officsr, treasurer or secretary of a legal entity or any person exercising similar authority.

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

[ j Yes No

If yes, please identify below (1) the name acd 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 jarnflial relatiocsMp, end (4) the precise n&tsre of such farralial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

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

Corporate InYtS+mthj- Hojitinjsjhc-

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[] the Applicant _t^rft \V
1. t-f^^g^al entity^/holdifig a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest:<5VAl/oy SmitS C\Ai(_t(JliQ NsYUJQQct P^^,

OR ^J LL-C

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: t)ht ftftf/pfl ?\ttt >l°0

(boj-hn un Quo®

Telephone:fr/7-fc2-7^f- 0ff k Fax: W Email: kcfuMfyg CAfM ^^en^
Name of contact person: fyftftUCt &hffmf?y
Federal Employer Identification No. (if you have one): j
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

HvME Ahitinj fir 51 oo /V- jtaHyni Avenue

Which City agency or department is requesting this EDS?_

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

Specification # f^H fiL^UCdhlt and Contract # /V'T 0^?f?l( Lzfofe

Vtr. 01-01-12

Page 1 of 13

SECTION tI-"D).SCLOS3Ja3 Q'0 LNTISSISTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing ! ] Person

[ JJ^ublicly registered business corporation f-j Privately held business corporation | } Sole proprietorship [ ] General partnership IJ Limited partnership f ] Trust

I j Limited liability company [j Limited liability partnership f I Joint venture [j Not-for-proStcorporation (Is the not-for-profit corporation also a 501(c)(3))? fi Ye;; []No ? Other (please specify)

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

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?

[lYes

[]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. KO'ES: For not-for-profit corporations, alBO list below ell members, if any, which are legal entities. If there are no such members, write "no members.'¹ For trusts, estates or other similar entities, list below the legal titleholderfa).

If the entity is a general partnership, limited partnership, limited liability compeny, 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. NOTjS: 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 Paity. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint veature,

Pa3p2of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a oust, estate or other similar entity. If none, state "None." HOTS: 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 £2^l\ disclosure.

Name Business Address Percentage Interest in the

. ■ Disclosing Party

frit-To* r^tfai CwftymvuflVL. I Whr\ VUct

 ! fyf&fr W&

024 ot?

SECTION IK->3U3TNe3S RELATIONSHIPS WtO CITY (CLSCT3D OFFICIALS

lias 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?

r ] Yes l/l No

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

SECTION IV -BCC.LOSU.aS 01? 3U3CQNTIUCTOS3 AND OT5S11 RETAINED ?A»TI2S

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 pcid. 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 iitan: (1) a not-for-profit entity, 03 an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of wbose duties as an employee of another includes undertaking to influence any legislative or administrative aotion.

If ihe 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 whcthsr 3usiness Relationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, £>aid or estimated.) NOT3:

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

not an acceptable response.

(Add sheets if necessary) /

[\jChesk here if the Disclosing Party has not retained, nor expects to retain, any such persons or aunties. SSCTIOK V - C5;aTIS7CATICHB

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Wnnicipal Cods Section 2-92-415, substantial owners of business entities that contract wiUi the City must rernsic in compliance with iheir 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?

ll Yes

[ J No person directly or indirccdy 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?

IjYes []No

B. FURTHER CERTIFICATIONS

1. Pursyant 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 ths Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any contiolling 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 revolving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or decsit against m 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 consplfanss timeuraoiss in certifications 2 and 3 below.

Pags!4of 13

2. The Disclosing Party and, if the Disclosing Pcrty is a legal entity, £1 of those persons or entities identified in Section ILB.l. of this EDS:

z. 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 crirninal offense, adjudged guilty, or had e. 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 ox 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 chaise B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more pubb'c transactions (federal, state or local) terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government

3. Tie 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, incrading but not limited to all persons or legal entities disclosed under Section IV, ''Disclosure of Subcontractors and Other Retained Parries");

" 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 orgam'zarion 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, ox, with the Contractor, is under common control of smother person or entity;

* any responsible official of the Disclosing Party, any Contractor or ecy Affiliated Earthy 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").

Pago 5 of 13

Naiiaer tije Disclosing Party, nor any Contractor, nor any Affiliated Entity ol 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:

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

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting wiih 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 of720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred. List
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.

1. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), (he Disclosing Party must explain below:

Page 6 of i3

lithe letters "NA," the word "Noae," 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 Icnowledge 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").

\A*>y\/^' , ,

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 "gi2r" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

i !¹³ Cilf^ not

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

2. If the Disclosing Party IS 8 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 jions of thsm will be coma, 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 cf doing business with the City."

If the Disclosing Party is unabfo 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 meaaing of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

In accordance with Ss^iion 2-155-110 of the Municipal Code: Does any official or smployee 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? /

L ] Yes b.fNo

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

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

Does the Matter involve a City Property Sale?

[JYes UNo

If you checked * Yas" to Item D.lprovide 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 foe Matter v/ill be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA 3USB4ESS

Flense check either I. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must iiszloss below or iii an at£a?hrnfint to this EDS all information required by paragraph 2. Failure io

Page3ofl3

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

^J 1. The Disclosing Party verifies lhat 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, mcluding the names of any and all slaves or slaveholders described in those records:

aacnoN yi - cb%tip?catioh3 *m m.o ssall y TfirNBurt) matters

WOTS: tftbe Matter Ls fefisrajfly ikad?d, complete this Section VI. Iftfca Matter >s not federally 1st.det?, proceed to Section VU. 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 L0B3YING

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 ox the Disclosing Party with respect to the Matter: (Add sheets if necessary):

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

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

Page 9 of 13

The Disclosing Party :nll submit an updated certification at the end of each calendar quarter in which there occurs any event thct 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 1985 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 end substance to paragraphs A.I. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

□ Yes

If "Yes," answer the three questions below:

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

fjYcs {]No

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

□ Yes r ]No

Have you participated ic any previous contracts or subcontracts subject to the equal ormorturrity clause?

[]Yes £3 Wo

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

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section vii- ACKN#?/£&o«»iwrs, coirr&Acx rNeo'firoBATJON,

COlVfJPL rANCS, i'SifAXOTS, DISC LOS VfXE 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 2-154 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, wo;k, 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 ibis EDS is false, incomplete or iaaccurate, 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 io make this document available to the public on its Internet site and/or upon request, Som? or all of the biformation provided on this EDS and any attachments to this ECS may be made available to the public os the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and sigmng this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any Information submitted in this EDS.

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

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

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

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

Chapter 1-23 of the Municipal Cods (imposing ?3ilMAN3NT IN £ "LI GIBILiTY for certain specified

offenses), the information provided herein regarding eligibility must be kept currest for a logger period,

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

The Disclosing Party represents and warrants that:

Page 11 of 13

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

F.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

(Print or type "name of person signing)

£Y?cashvi Vat PttJtdurr-

(Print or type title of person signing)

Page 12 of 13

Signed and sworn to before me on (date) /1/f (i^ % ? 0/3>_tat , J iff "fa ]£■ County, M# (state).

CITY Off CBXC&SG ZCONOMTC I'JSCLOSUjttE STATEMENT AND APFIDAYTT

A??BSf?aCCA

^AMSLJAS, StKLilTIONSfflPS WCft 1 SLBC7SD CITY OFFICIALS AHfi T>K?A*TMSNT HMDS

Tl'la Appaarr& ?i ;o ^s^aplsrsd *£ly by (s) iisa Appear;;, eati'(b) miy lags! astfiy vrh'eia luis a rfirsci 3V/Q«if5ista 5biyrMt iii lk2 As^ttm-t Erssatflas 7.5 >ir«pt. Iris r»o* to be sroasplofoc! iry ay l2gal erviry wilea ires an!^ rei tadtesc;; ownarr /up ir. fsrssi fc iiw Ajni^caai.

Under Municipal Code Section 2-154-015, the Disclosing Party mutt disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thewof currently has e "familial relationship" with any elected city official or department head. A ''familial relationship" exists if, as of the date this BDS is signed, the Disclosing Patty or ajy "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 Hi's following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, rather-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or steptnother, Btepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section HJ3.1 .a., if the Disclosing Party is a corporation,- all paitacrs of the Disclosing Parry, if the Disclosing Party is a general partnership; all general partners snd limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; ad 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, "ftindpal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal satity or any person exorcising similar authority.

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

UYcs

If yes, please identify 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 of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

2>oSi*r\ tqnW> hrtnrYS torpore^hin

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

{] the Applicant ^w-KTD
f-f a legal entity holdiftg-a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interesticSVfl/QK&U(jq Ckif.fldQ NoYUJQOct

OR ⁰

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: f)ftt fhnf-fvn ?\dCt ,&Ul~fc >l00

fo0JH>n AAA

conn
Telephone:fr/7-friY'-f$g-Cyfr Fax: ^l7'(plf-Email: bchw/yc?b^-fa/lCdf/t^
Name of contact person: fir enact CMtmpvj

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

Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

-hhiuncj tW 51 oo /V- faHvrh AVtfiuc

Which City agency or department is requesting this EDS?_

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

Specification # A/W {bfft]lCClhlC and Contract # /VW fl^pl I id bl^tZ

Vcr. 01-01-12

Page 1 of 13

8SCTOH II - BIBCL05U&% OP OWNERSHIP INTERESTS

A. NATURE O? THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing (] Person

{ } Rubbery registered business corporation \jf Privately held business corporation [ ] Sole proprietorship [ { General pcitnership I ] Limited partnership U Trust

[ ] Limited liability company

[ ] Limited liability partnership

f j Joint venture

f j Not-for-profit corporation

(Is the not-for-profit corporation al3o »501(c)(3))?

[ ] Yes [ ] No

1 ] Other (please specify)

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

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?

L]Yes ISJNo NiWA

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

i. List below the full names and titles of all executive officers and all directors of the entity. PI GTS: 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 titlcholder(s).

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

Name Title

Oik* P-itvEnmnfi ^rmtelM} Pirfbfoy

Marc fN - TtaJ s^v^'f fovTftgsuvrr, ftu-t CIcyT-

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. E:<camples of 8ucJi an interest include shares in a corporation, partnership interest in a partnership or joint venture,

Page2cf 13

interest of a member or manager in s limited liability company, oi* interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOV 2: 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 fall disclosure.

N&ibe Business Address Percentage Interest in the

Disclosing Party

1 Hue-

fft^tTiL? fo\foayjU_t. Smit W joo h

ssctxois ra - susihjess rslat tcnskipg with C2TY.28LSCT*ii5 os-sicxals

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

I; Yes pi No

If yes, pleas* identify below the iuune(s) of such City elected official(s) and describe such relationship(s):

SJ2CTKONIV - DISCLOSURE OP SUBCONTRACTORS AND OTHSR 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 tha Disclosing Party has retained or expects to retain in connection with the Mutter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

■'Lobbyist*' means any parson 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" cko means rury person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

Ii" the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City v/hsther disclosure is required or make tho disclosure.

Page 3 of 13

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

rjtcincd or anticipated Address (subcontractor, attorney, paid or estimated.) NO If.S:

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

not an acceptable response.

(Add sheets if necessary)

[vf Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SISCTZOW V -r CiSATaG'NS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Uadiir Municipal Code Section 2-92-415, substantial owners of business entities that contract with tio 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 obb'gations by any Illinois court of competent jurisdiction?

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

Disclosing Psrty.

I* "YC8," has the person entered into a court-approved agreement for payment of all support owed and is the person in complijtnoc with that agreement?

£ 1 Yss [ ] 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 tho Disclosing Party submitting this EDS is the Applicant and is doing business with die City, thai) the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person iB currently indicted or charged with, ox has admitted guilt of, or has eve? 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 as officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article l ifi a continuing requireincnt for . doing business with the City. NOTE: If Article I applies to the Applicant, Qie permanent compliroice timeframe in Article 2 supersedes seme five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

identified in Section UJ3.1. of this EDS:

a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by arty federal, state or local unit of government;

t. have not, within a five-yezr 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; their; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;

are not presently indicted for, or criminally or civilly chcrged by, a governmental entity (federal, state or local) with committing any of tho offenses set forth in clause B.2.b. of thiB Section V;
have not, within a five-year period preceding the date of this EDS, bad oue 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, beeu convicted, adjudged guilty, or found litble 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, A end 5 concern:

*the Disclosing Party;

- any "Contractor" (mearing any contractor or subcontractor used by the Disclosing Party in connection with the Mutter, 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 end equipment; common use of employees; or organization of u business entity following the inaudibility of a business entity to do business with federal or state or local government, mcrcding the City, using substantially the sarnc management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity meanc a person or entity that direcdy or mdircctly coatrols the Contractor, is controlled by it, or, with the Contractor, »b under common control of another person or entity;

* any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other ofiicicl, agent or employee of the Disclosing Parry, 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").

p£ge5of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Bntity 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:

1. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, Che State of IQiaois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
2. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, iu restraint of freedom of competition by agreement to bio a fixed price or otherwise; or
3. marie an admission of such conduct described in a, or b. above that is a matter of record, brt have JiOt been prosecuted for such conduct; or
violated the provisions of Municipal Cod? Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agentB or planners, is barred from contracting with any unit of state or local government us a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-roiating h: violation of 720 ILCS 5/33E-4; or (3) any sheilar 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 Bntity 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, dia Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-S5 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unfible to certify to any of the above statements in this Part B (Further CertijEciitioas), the Disclosing Party must explain below:

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable mquiry, 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 coursu of official City business and having a retail value of less than $20 per recipient (if none, Indicate with ^WN/A" or "none"). As to any gift listed below, please aho list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

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 Paity pledges:

"We are not and will not become a predatory lender ds defmed in Chapter 2-32 of the Municipal Cede. 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 predator lender or becoming an affiliate of £ predatory lender may result in the loss of the privilege of doing business with the City."

If thw 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 hare (attach additional pages if necessary):

Pfege7of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

1. In accordance with Section 2-155-110 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? /

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

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, uo 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 m 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 tukea pursuant to the City's eminent domain power does no; constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

£3 Yea []No

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

Name Business Address Nature of Interest

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

fi. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Pege 8 of 13

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

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

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

srcjhoh vj - cs?;raxcATioNS'tfO& fisdskally z-'unbed mattsrs

NOTiS: i f lbs Mztiis? is fedtr.iJly funded, complete this Section VL If the Mcttoi* $3 net fWersUy Ivztiz'l, proceed to Section VII. For purposes of this Section VI, tax credits sllocated by the City and proceeds of debt obligations of the City we not federal funding.

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of sll 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 appeals or begins on the liaes above, or if the letters ⁿNA^H or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means thtt NO persons or entities registered undar the Lobbying Disclosure Act of 1995 h&ve made lobbying contacts oa behalf of the Disclosing Party with respect to the Matter.)

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

Page 9 of 13

The Disclosing Party wUl 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 auration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is tU»i Disclosing Party the Applicant?

[ Yes f^No If "Yes," answer the three qucctions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 4i CFR Part 60-2.)

f-Yes UNO

Have you Hied with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or die Equal Employment Opportunity Commission all reports due under the applicable filing requirement:,'?

1 Yes [ ] No

Have you participated in any previous contracts or subcoatracts subject io ths equal opportunity clause?

[]Yes HNo

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

Page iOof 13

sjscn.ow y.u - acxno wuu> gments,- cd ntsia' err mcc^pdration,

COfelFLJANCS, ?3NALTIK3, BISCLOSUAjS 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 snd 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 oil statutes, ordinances, and .eguiatians on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of tha 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 r* training program is available ou line at www.cityofcaicago.org/Ethics, and may also be obtained flrom 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 informatioa 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, ?ad the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or m equity, including terminating the Disclosing Party's participation iu the Matter end/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law fox a false statement of material fact may include incarceration and an awaid 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 pubb'c release of information contained in this EDS and alco authorizes the City to verity tie accuracy of any information submitted in this EDS.

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

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

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

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

Chapter 1-23 of the Municipal Code (imposing PaftMANSNX INlDLiCri3.TLTry for certain specified

offenses), the infcnu*tion provided herein regarding eligibility must be kept entreat for d longer period,

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

The Disclosing Party represents and warrants that:

Page i j of 13

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 MatteT 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.lF.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

rhrme of

botfon fMfiwf PtiHrrert Corporcrti^on

(Printer typejfame of Disclosing Party)

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

Signed and sworn to before me on (date) jfA^^j 1 S> ^

at Juf-fatjC- County, }Y)fl (state).

ftAA/UM^- fb^^^^^y^^ Notary Public. Commission cxpires:_

Page 12 of 13

cxreoF-cmcAGo

ECONOMIC jaSCLOSMJa* STATBMBHT AND AF.PTOAYI? APP.6NDZXA

FAMSUTAi, JUSTICESHIPS WITT* 3£J£Craj> CTTY OFFiCULS ANDiSKfAH^OSNT HEADS

This Ajji^ldbr. b ■:■> b ) ej-spihteu a Ply Uy (c) $19 AypXtess!^ ftT?d (b) r*ay legal 3i»iiry TZhtek has a direct OWfisnbto k<icr?it Irs irw AapBscai axcstSliig TJ *!»SJTS3.ii jft fe aat oo be eocso!e£^ by nay lagnl fatitiy wfevcb law oaly aa iaiilrectinvnsnTuc tatsrastlo tfia A«iTiiicr,.ui.

Undsr Municipal Code Section 2-154-015, toe Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or airy Spouse or Domestic Paztnesr thereof currently has a "Jaminal relationship" with any elected city official or d^nruncnt bead. A 'Yarrtflial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Pariy" or any Spouse or Domestic Par mer thereof is related to the mayor, any aWerrntn, the city clerk, the city treasurer or tny city deportment head spouse cr domestic pertner or as any ox the foUowing, whether by blood or adoption: parent, child, brother or sister, sunt or uncle, niece or nephew, grandparent, grandchild, fathcr-in-Jiw, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson o? stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party''means (I) all executive officers of the Disclosing Party listed inSection H.B.1 a., if the Disclosirjg Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is n general paruaership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited parteersuip; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) nil principal officers of the Disclosing Party; and (3) any person having more then a 7.5 parceut :b\vnersbip interest in the Disclosing Petty. *Trincipal officers" means the prwddsmt, chief operating officer, executive director, chief financial a facer, treasurer or secretary of a lagol entity or cny person exercising similar Authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "£urtiliai rtlatioashdp" with an elected city official or department h-xid?

[ ]Yes [vjNo

XT yes, please identify below (1) the name and title of such person, (2) the mane of the legal entity to which such person is connected,' (3) the name end title of the alerted city official or department head to whom such person bits s familial relationship, and (4) the precise nature of such farnilutl relationship.

Pago 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

I 1 the Applicant . v_.
1. f-j i legal entity⁷!holding- a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interesf.cSVrKOK litS ChtCCHV NOYUJOOcl P^^

OR ⁰ lit

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: f)nC P)to(iv)\ PltM . farfc >l^&0

boJtv'n AAA

Telephone:fr/rfr2Y-0gfrfr Fax: W7-(pVf-&911 Email: ychm^b^CdfM-^^>
Name of contact person: QftftdU CMtjryijPVJ
Federal Employer Identification No. (if you have one): j
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

HroMfi &MtUnj ?W 51 oo /V - H*Wtrri Avthuz-

Which City agency or department is requesting this EDS?_ HUP

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

Specification # and Contract # &ff?l liable

Ver. 01-01-12

Page 1 of 13

3iic?:Tcw n -tewcLvsum of owrnKsm? sntizrssts

A. NATURE C? THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

I ] Person f) Limited liability company

[ ] Publicly registered business corporation f J Limited u'abiliry parinership

[Vj Privately held business corporation [ ] Joint venture

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

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

j Limited partnership [ ] Yes [} Ns

[] Trust [J Other (please specify)

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

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

J Yes M*No (? N/A

B. IF THE DISCLOSING ;'ARTY IS A LBGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. MOTS: 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 titleholderfs).

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 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

H&ti V4-Tt*U 5V9, fcrt.TYemuvfcy > AiSKav/t-

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 includs shares c corporation, pnrtnership 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, sstate or other sirailar entity. If none, state "None." irOTH: 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 mil disclosure.

Name Business Address Percentage Interest in the

 , Disclosing Party

1 oxtog

section lu-vcus nmss B£i*A?j.Qmw&s--m'TU city ssjectjcb omccALs

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 3DS is signed?

I j Yes [J] No

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

SJSCTEONIV - DI3CLG3U.ft.7r. OF SU3CGNTIIACTDP-S AND GT3L2U 33TAIN2D ?AJStTI33

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 ic connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ssk the City whsther disclosure is required or raaks 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.) NOT 3:

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

not an acceptable response.

(Add sheets if necessary)

[./Check hers if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

section v - cs&rmjCAXJQm

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-415, substantial owners of business entities that contrast 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 besn declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ j Yes [vjNo [ J No person directly or indirectly owns 10% or more of the

Disclosing Party.

If "Yes," has the peTsoa catered into a court-approvsd agreement for payment of all support c-wed and is the person in coraoliance with iat agreement?

i ] Y*s H No

3. 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 requirsmaats), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (a) neither the Applicant nor any controlling person is currently indicted cr charged with, or hes admitted guilt of, or has ever besn coavicted of, or placed under supervision for, any crimuial 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 3omg bv.smsss with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timsiiaine in Article I supersede? some five-year compliance timeframes ia certitrcaiicus 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 ILB.l. of thiB EDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against mem 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 crirninally 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; end
have not, within & five-year period preceding the date of this EDS, been convicted, adjudged guihy, 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;

Hny "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 TV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity mat, directly or mdirectly: 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 frjnfly msxabers, shared facilities and equipment; common use of employees; or organization of a business entity following the msiigibility of a business entity to do business with federal or state or local government, including the City, using substantially the sane 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 muter commas control of ano ther person or entity;

* any responsible official of the Disclosing Party, any Contractor or any Afnlitted Entity or cny other official, agent or employee of the Disclosing Party, any Contractor or aay Affiliated Entity, acting pursuant to the direction or authorization of a responsible officio! of the Disclosing Party, arty Contractor or any Affiliated Bntity (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 auy Agents have, during the five years before the date this BD3 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, r. 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;

"i>. 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

1. made an admission of such conduct described in a. or b. above that is a matter of rscord, bci 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 iocal 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-riggmg or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors; the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Eatity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

If the letters "MA," 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 mquiry, the following is a complete b'st of all current employees of the Disclosing Party who were, at any rime during the 12-month period receding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete iist 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 varus of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gut listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

a "fincncial institution" as defined in Section 2-32-45S(b) of the Municipal Code.

2. If the Disclosing Party IS a financial institution, then the Disclosing Pzrty 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 ss defined in Chapter 2-32 of the Municipal Code. We understand that becoming ft predatory lender or becoming an affiliate cf a predatory lender may result in the loss of the privilege of doing business with the City.'^r

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-4S5(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST LIT CITY BUSINESS

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

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City iiave a financial Lttstest in his or her own name or in the name of any other person or entity in ths Hatter? /

[ j Yes (^No

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

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold .7or taxes or assessments, or (iii) is sold by virtue of legal process atthe 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?

IJ Yes [ ] No

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

Name Business Address Nature of Interest

4. - The Disclosing Party iurtber certifies that no prohibited fjnancid 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 >nust disclose below or in an attachment to this H5DS all information required by paragraph 2. Failure to

PdgeSor 13

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

. V . 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damcge 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 cbove, the

Disclosing Party has found records of investments or profits frojc slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including th-3 names of any and all slaves or slaveholders described in those records:

3BC710K \n -- cbr

ITTjWCATXGMS ?G& PS^SS^JLLY ?UNB >SO M&TT3&S

MOTS: if &i iilatts.-: la federelly fundad, complete this Section VL If iiie Mails*- Is ac£fed?srs?Jy rumf'Ks proceed to Section VH. 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 v/ith respect to the Matter: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" Appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1595 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 expand any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or Attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any fader ally funded contract, making any federally Rinded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify cny federally funded contract, grant, loan, or cooperative agreement

Page 9 of 13

7fce Disclosing Party will sub-nit 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.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Intern?! Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the iatemal Revenue Code of 1986 Imi 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 end 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 fedsrally f'taded, federal regulations require the Applicant a^d all proposed subcontractors to submit the fallowing information with their bids or in writing at the outset of negotiations.

Is the Disclosing Patty the Appticant?

[]Yes

If "Yes," answer ihe three questions below:

2. Have you deveiopad and do you have on file affirmative action programs pursuant to applicable

federal regulations? (See 4! CFR Fart 50-2.)

E i;Ye3 { ] No

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

[jYes NNo

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

[JYes []No

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

Page 10 of 13

SECTION Vlt AC&MO WLSSGMBWTS, C£Hr£»ACT INCORPORATION, COM I'LIAN C12, JPjSKALTI353. .0 iS CLO SURE

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 Giber acticn 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 roll text of these ordinances and a training program is available on lino at www.citvofchicago.org/EthicB. and may alBO be obtained from ihe City's Board of BthicB, 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 iB submitted mey 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, memding terminating the Disclosing Party's participation in the Matter and/or decliriing 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 io the City of treble dcmagcs.
It is the City's policy to make this document available to the pubhc on its Internet site and/or upon request Some or all of the information provided on this EDS and any attachments to thi3 EDS may be mads available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. 3y completing and signing this EDS, ths Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the pubh'c 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 svest of changes, the Disclosing

Party must suppiemsnt ibis ED3 up to the time the City takes action on the Matter. If the Matter is a

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

update this EDS as the contract r^oires. N0T3: With respect to Matters subject to Article I of

Chapter 1 -23 of the Municipal Code (imposing FE&MANJSNT l&ZLZG3ttJJVIY for certain specified

offenses), the information provided herein regarding eligibility must be kepi cuiTeut 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:

Pagel. of 13

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

(Print or type^hame of person signing)

fcifCdiiVf, Vice frtx\fJtn+

(Print or type title of person signing)

Signed and sworn to before me on (date)

at ^ijv)[t- County, fY)ft (state).

Notary Public.

Commission expires: jVi2-2~//*>~

Page 12 of 13

CITY Off QrftGAOO

scgwgmxc jkbcxoshris ssAimm? Aim £xtm*yf?

Tola ArjpariDix & to 2?3 C9iiic»22^d s-iiy J?y (o) &e Appilcrrci, cad (b) any ;sgaJ an«U7 winch Jsa» n direct STKastsffig-istittsi fo tf»3 Aprj^cssr nxsttdlng 7.5 tjwjsv, .?* »snot to c»iii;»iet3d by asy iigti esrify

Under Municipal Code Section 2-154-015, the Disclosing Party roust disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any ejected city official or department head. A ^<<farnibal relationship" exists if, aB of the date this EDS is signed, the Disclosing Parry 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 adoptiba: parent, child, brother or sister, aunt or uncle, niece or nephew, godparent, grandchild, Ihther-in-hw, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed is Section ILBJ .a., if the Disclosing Party is a corporation; all perUers of the Disclosing Party, if the Disclosing Parry is a general partnership; ell 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 habimy company; (2) all principal officers of die Disclosing Party; and (3) any person having mere than a 7.5 percent ownership interest in the Disclosing Party. 'Trincipal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or firry person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Parmer thereof currently have a "fcxnilial relationship" with an elected city official or departrnsnt head?

[]Yes MNo

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

Jft?3e 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION J -- GENERAL INFORMATION

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

Boshr) CtLf\-M (owpfh/on Lim/ifd PtHnmh /p

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[]the Applicant ^ _t^_t(frW
1. £-jalcgal entity/holdiftg a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an mterest:<SVn/0/' &UtjtS CfaiCajfV NDfUJ(?0ct PdfK-,

OR ⁰ CtC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: f]f[l ftftf-fcfl Phct Aurfc >lOO

(boJfon AAA 07-10&

c-t>nn
Telephone:^_2__________ Fax: bl7~0>lY~ 8 ?M Email: hchmf^eCAfM
Name of contact person: 0 Ytft CMtt mj^^J

E. Federal Employer Identification No. (if you have one): ■■'

Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

tblUE AhfUnj tV Slop /V- {faHtni Avtnuc

Which City agency or department is requesting this EDS?_

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

Specification # A/W Ajflhcubit and Contract #

Ver. 01-01-12

Page 1 of 13

SRCT/.ON S.% - EXSCLOStHsUs Oi⁷ 0WN33SHB*

A. NATURE O? THE DISCLOSING PARTY

I. Indicate the nature of the Disclosing f ] Person

[ 1 Publicly registered business corporation [ 1 Privately held business corporation [ j Sole proprietorship 11 General pertnersbip l\yLiniited partnership [ ] Trust

Party:

( ] Limited u'ability company

[ ] Limited liability partnership

1 j Joint venture

f' Not-for-profit corporation

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

[]Yes []No [ ] Other (please specify)

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

3. For legal entities net organized in the State of Illinois: Has the organization registered to do business in tie State of Illinois as a foreign entity?

[IN/A

B. IF THE DISCLOSIN G PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. HOT'S: 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).

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 ihat controls the day-to-day management of the Disclosing Party. N'DTS: 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 eaiity having a direct or indirect beneficial interest (including ownership) in sxesas of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest ia a partnership or joint venture,

Page 2 of J3

Name Business Address Percentage Interest in the

TWpKr fr>uH,Dm Disclosing Party

VokuJPffHfie&InC- & ttditr, -HHe<jj Cfannci Isiim'S j^/ W/-

Vol aw ^(M//^ ^ to<+Mn >

-Jwn p- Menming //fawn mft 07-1 o$ l/l/ cfq j,

y 5--A J

Muffle fHfty Umifref Papier J' (/wit ^l.mitffll 2o^J/, [nont b»"H* m-f*rr<sA

SECTION HI -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[]Yes []No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

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

Page 3 of 13

Name (indicate whethsr 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 "Lb.d." is

not an acceptable response.

(Add sheets if accessary) ✓

|v} Check here if the Disclosing Party baB cot retained, nor expects to retain, any such persons or entities. S3CTTON V - CERTXFi CATTC'NS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code S-sction ?.-92-415, substantial owners of busiaeas entities that contract with the City must remain m comphance with their child support obligations throughout the contract's term.

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

j]Yes

i ] No person directly or mdirectly ov/iis 10% or mors of the

Disclosing Party,

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

[ j Yes [ ] No

3. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1 -23, Article 2 ("Article FX^bich the Applicant .should consult for dean ad terms (e.g., "doing business") end legal requirements), if the Disclosing Party submitting this EDS is the Applicant and fa 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 hss admitted guilt of, or has over bean convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, frcud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or nny sister agency; and (ii) the Applicant understands and acknowledges float compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance timefr&nse in Article I supersedes BOtne fivs-year compliance timeframes in ccrtilioiu'ons 2 and 3 below.

Page 4 of 13

2. Tie Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section H.EU. of this EDS:

a. , 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;

hcve 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 ihsra in connection with: obtaining, attempting lo obtain, or performing a public (federal, state or local) transaction or contract under a pubb'c transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction cf 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 comrmrting eny 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, bad 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, bean convicted, adjudged guilty, or found liable in a civil proceeding, or in any crivn.<a_l 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 ic subparts 3,4 and S concern:

' the Disclosing Party;

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

any "Affiliated Entity" (meaning a person or entity that, direcdy or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under ccinmon control af 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 nse of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or stata 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 CoritrEetor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible ofScial of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 3 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 ihc date of such Contractor's or Affiliated Entity's contract ox engagement in connection with the Matter:

1. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the Stats 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 o facial capacity;
2. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by apeement to bid a fixed price or otherwise; or
3. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
vialated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (I) bid-rigging in violation of 720 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 tho 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 Dsnied Persons List, the Unverified List, the Entity List and the Debarred List
Tins Disclosing Party understands and shall comply wife the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (GovOTunerrtal Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statemeuts in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

If the letters "NA," the word "None," or ao 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 al! current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").

9. To the best of _e Disclosing Party's knowledge aXter 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 end having a retail value o f less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also Est the name of the City recipient.

C. CERTIFICATION OP STATUS AS FINANCIAL DESTITUTION

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

[ J is y is not

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

If the Disclosing Party IS a financial institution, then ibe 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 dofxaed in Chapter 2-32 of the Municipal Coda. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

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

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that tha 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 msailings when used in this Part D.

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

[] Yes bfao

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

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other parson or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, of (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Froperty 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.

Doss the Matter involve a City Property Sals?

{ : Yes [ ] No

If you checkiid "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 Dissloamg Party :rurther c^i^ be acquired' by any City officio! ox 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 3 of 13

comply with these disclosure requirements rcay make ary contract entered into with the Gity in connection with the Matter voidable by the City.

' 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance pob'cies 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 [>olicies. 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:

SECTXDH VS- C2STf?fCATi£>NS *G& f3SD9St&JAY Wilms® itfATTJEaS

JT?CT»: Iftha itf altar la isSv&Hy ftra&j, cosnplste this Section VI. 51 the Mottle is flot sVJeraifJy iVadbci, 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 LOB3YING

(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 Petty means that NO persons or entities registered under the Lobbying Disclosure Act of 1595 have mads 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. I. above for bis or her lobbying activities or to pay any person or entity to influence cr attempt to influence aa 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 losn, entering into any cooperative agreement, or to extend, continue, renew, -lacend, or modify any federally funded contract, grant, loan, or cooperative agreement

Page 9 of 13

The Disclosing Petty v/ili submit an irpdated certificatiDn at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements guu information set forth in paragraphs A.l. ead A.2. above.
The Disclosing Party csrtifies that either: (i) it is not an organization described ir. 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, th<» Disclosing Party must obtain certifications squal in form and substance to paragraphs A.l. through A.4. above from ell 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 ia federally funded, federal regulations require ths 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 ths Applicant?

M Yes

If "Yes," answer the three questions below:

r 1 No

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

HYes

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 resorts due under the applicable filing requirements?

HY^ II^No

3. Have you participated ic any previous contracts or subcontracts subject to the equal opportunity clause?

[]Yes f_]No

If you checked "No"

to queation 1. or 2. above, please provide an explanation:

Page 10 of 13

sacTiOM vn - Acx<NcwLjaT>GM.em^,s,-contract iwco^okatich,

COMPLIANCE, PINA LTI>23, DISCLOSURE The Disclosing Party understands and agrees that:

Ths 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 2-155 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 trairiing program is available on line at www.ciWofoMcano.orK/B1hics. and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick 3L, Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party mart 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 »aw, or in equity, mcroding terrnmating 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 fast may include incarceration and an award to the City of ireble 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 SDS may be made available to the public on the Internet; in responss to a Freedom of Information Act request, or otherwise. By completing and signing this SDS, 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 BD3.

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

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

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

update this EDS as the contract requires. I1C-T3: With respect to Matters subject to Article I of

Chapter 1-23 of the Mrjnicipal Code (imposing PSRftlAN vSNT jCNEilCpILZTY for certain specified

offenses), the information provided herein regarding eligibility must be kept current for 3 longer period,

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

The Disclosing Party represents and warrants that:

FRgel:of 13

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

(Printer type name of Disclosing Party) , . ^ //-)

By: '^^/f\T%/f

(Print or typfc'name of person signing)

(Print or type title of person signing)

Signed and sworn to before me on (date) j^Aci^j 5® % ^ at <fHjfDl^ County, /ft& (state).

Notary Public.

Page 12 of 13

CTFY OF CBJCAGO APPENDIX A

SAJVGLTAI/ SSLAYXOxSS.BiPS WSTa 1LBCT8SB CTTY OKBKSALS ARD D2L*ARTM2NT SESADS

This ApTiK5«ls *■! i» bs-somsiiejaa oaly by (a) Applies?.?, aMCv{b} RCflzgpl zzSty whlrb iira & Srsrt owa«.ni*j? ta£'?u'a3£ t! t-j-i A>>p3;KtTii rcrcesllag 7.6 pitrsaAf. Ii a actio b° sauFuiafeKi by aay bgcS sstity w&iclt ten <raly fcidbwj 0rV£2fsMp iRfwsst h\ she ApaJieasir.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether sacJi Disclosing Party or aay "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "famiEal rektianship'* with any elected city official or department head. A ''familial relationship" exists it; 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, steprather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all exenrtive officers of the Disclosing Party listed in Section HB.l.a^ if me Disc losing Party is a corporation; r U 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 hability company; (2) ail 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 Pertner thereof currently have a ''familial relationship" with an elected city official or department head?

{ J Yes jS^No

If yes, please idecfiry 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 parson has a familial relationship, asd (4) the precise nature of such familial relationship.

Page 13 of 13

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:

Bcsfth Ca-fiMj? Party? JC toypor tut?on

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [ ] the Applicant

or strkid ttpeort

2. a legal entityboldisg-a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest^n/Of SutitS Chf£ff0D NoruJQGd

OR ⁰ LLC

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 of the Disclosing Party: flnt ftftffPfl PUct Autjc 7-7 PO

&0JH>n AAA 00-IQ&

Telephone^T-feZY-^gfefr Fax: Email: ycMm^6b°^CAfM-C»rn
Name of contact person: QrCHctff CMaWlfOVJ

Federal Employer Identification No. (if you have one): ,' . _t
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):

tfaMB -f*h(Unj tV 57°° N- HaHzrr, Avenue,

Which City agency or department is requesting this EDS?_

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

Specification # A/W juffl)i cable, and Contract #

Ver. 01-01-12

Page 1 of 13

section it - siscLQsuafi of c vtkzrsri? wTEnaS'TS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

[ j Person

I ] Publicly registered business corporation Jy3 Privately held business corporation

[ ] Sole proprietorship i J General partnership [ ] Limited partnership

II Tract

[ J Limited liability company

[ j Limited liability partnership

[ 1 Joint venture

t ] Not-for-profit corporation

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

[ ] Yes [ ] No

[j 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: Hub the organization registered to do business in the State of Illinois as a foreign entity?

[v/Nc

? jYes [vJNo I IN/A

B. IF THE DISCLOSING i>ARTY 13 A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and a"! 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 trtleholder(s).

If ths 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. tfQTZ: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

.jnlii. P.tannine jffSitktMj Pifccfor

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) is excess of 7.5% of the Disclosing Party. Bx&mples of such an interest include shares in a corporation, partnership i:iexest ic 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 rei] disclosure.

Name Business Address Percentage Interest in the

I n_ a Disclosing Party

yji)^ ?-fcftmi\m 1 >£tw fto,

i\>n ncm^TtMs^ font*. u»& W)'\-

n\Q9>

sacnow m -ausiNiiss relationships with city el3cish3 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 \f[ No

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

S15CTTGN IV - OF SUBCONTRACTORS ANB 9THS3 ?A3T18S

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

Page 3 of 13

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

retained or anticipated Address (subcontractor, attorney, paid or estimated.) MC7.8:

to be retained) lobbyist, etc.) *TiourIyrate"or"t.b.d.^Mis

not an acceptable response.

(Add sheets if necessary) /

fa Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SaCTJON Y -- DOTTCSCATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Saction 2-92-415, substantial owners of business entities that contract with iie 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?

I ~< Yes 5»^No »" ] No person directly or indirectly owns 10% or more of the

Disclosing Party.

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

HYes []Nc

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter I -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 has admitted guilt o£ or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, etteaapted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of ths City or any sister agency; and (if) the Applicant understands and acknowledges thst compliance wiih Article I is a continuing requirement for doi/ig business with the City. NOTE: If Article i applies to the Applicant, ihs permanent complirmcs tiisetrcme in Article i supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party end, if the Disclosing Party is ft legal entity, all of those persons or entities identified in Section II.3.1. of this BDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or vohurtarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had s civil judgment rendered against them in connection with: obtctiijg, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state entitrust statutes; fraud; embezzlement; theft; forgery; briber}'; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of 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 BDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have cot, 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 end 5 concern:

the Disclosing Party;

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

any 'Affiliated Entity" (meaning a person or entity that, directly or mdirectly: controls tho Disclosing Party, is controlled by ths Disclosing Party, or is, with the Disclosing Party, under common control of another pesson 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 Ciiy, 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 thai 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 of any other official, agent or employee of iae 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 eny Affiliated Entity of either the Disclosing Party or any Contractor nor eny Agents have, dming the rive years before the date this EDS is signed, or, with respect to a Contactor, 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, ths 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;

V». 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 ELCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with ths applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is ratable to certify to any of the above statements in this Part 3 (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

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

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this SDS, 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 520 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ j is k| is Tiot

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

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

"We are not and will nor 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 cf them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

Page 7 of 13

If the 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 3USINESS

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

In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter? / [)Yes {^No

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

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

Does the Matter involve a City Property Sale?

f]Ycs iJNo

3. If you checked "Yes" io 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

1. The Disclosing Party further certifies that no prohibited iintneifil iriterest m the Matter vrlll be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVER Y ERA BUSINESS

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

Page 8 of 13

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

^v __1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step ! 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 SaU disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

3I5CTION VZ- CSKTIFICATICNS FOD2S.RALLY FUNDUS MATTZT13

NOTE: If fts Mftitw h fcJeraily fasui-i, complete this Section VI. Xf toe Maitar is aoifefle^aay Irjt Sad, 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 daisies 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 necsssary):

(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 rsgistercd under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to ihe Matter.)

2. Ths Disclosing Party has not spent and will not expend any federally expropriated funds to pay any person or entity listed in Paragraph A. I. above for bis or her lobbying activities or to pay any person or ratify to influence or attempt to influence an officer or employed of aay agency, as defined by applicable federal law, a member of Congress, sn officer cr employee of Congress, or an employee of a member of Congress, in coansctiaa with the award of any federally funded contract, raaViag any federally funded grant or loan, entering into any cooperative agreement, or io extend, continue, renew, amend, or rrscdify any federally funded contract, grant, loan, or cooperative agreement

Fage 5 of 13

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

501 (cX4) 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 AA. 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. CBRTD7ICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

is ;he Disclosing Party the Applicant?

[1 Yes

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 4l CFR Part 60-2.)

[ ] Yes { j No

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

IJYct [JNo

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

[]Yes UNo

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

Page 10 of 13

33EC7TON v'li - ACJ&tQWL&OG&mHTS, CONTRACT TNCO.fip?'OBiVfiP?l-, COMPLIANCE PSNA.LTBSS, DISCI.05t7aL2

The Disclosing Parry understands and agrees thBt:

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 talring 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 Fintncing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, woi-k, business, or transactions. The full text of these ordinances and a training program is available on line ai www.cityofcriicago.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 iB 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 iachids incarcci-ation and an award to the Chy of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon rsquest. 3om= or all of ibe 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 3y completing and signing this EDS, the Disclosing Party waives end 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 die City to verify the accuracy of any information submitted in this SDS.

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

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

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

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

Chapter 1-23 of the Municipal Coo's (imposing PSiWANINT 2K2E3»£GISXL1T¥ fox certain specified

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

as leqou'iSd by Chapter i-23 and Sectioa 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

page 11 of 13

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

F.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

ftosfrn CdUffrhtiL far+f\*rt& torpof^hon

(Print or mie narmf <tf Disi^eam&Party)

(Sign hWe)

(Print or type name of person signing)

£)CfCtohyz Vim PffJtctetnf

(Print or type title of person signing)

20,10/2

Signed and sworn to before me on (date) /Uf /tjj at L^LTffll^ County, /Wfl- (sta4e).

PlAJ^M^J^- y&^^fay^yT^ Public. Commission expires: /0

Page 12 of 13

CTT7 DP ClfXCAGO 3COKOJS3KC DI3CLOSU&S SSA±Wmr AKD A^jftOAViT

?/JViILlAL YtJOATZONSHZES 'WITHELSCTED CiS'i' OPPtOA&S AJ^JiSPAHIMlSPfr HIS ADS

This Append!';^!s ic In ttrrsp'jsfcsd only I17 (a) ApeSsasi, (b) ar>7 l*g«* en'-iiy wisl.-Ji Ssss a -iirect mri.-eTc!:^ int-srcai h; lb a Aaptfc^t wc-'xeaiag 7-5 j»r*is£t. aoi :o be eaTsial&'.vlwy i?r,y Je^ai SKSry Vfifoa c^Jy us feilr^iCTTasratrp fc>*er*s£ Is* ti? Ape tfcaat.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party ox 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 mis EDS is signed, the Disclosing Party or any "Applicable Part/* or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any chy department head as spouse or domestic partner or as any of the foUowing, whether by blood or adoption: parent, child, brother or sifter, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-lcw, mowtf~rn-Iaw, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section HB.l.a., if ths Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more man a 7.5 psreeat ownership interest in ths Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief fimmnMil 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 M'no

If yea, please identify below (1) the name end title of such person, (2) the same of the legal entity to which such person is connected; (3) the name and title of the elected chy official or department head to whom such person has a famflial relationship, and (4) ihe precise nauxe of such familial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Jdh P- Mtnninj AW PeYoC*t?lt, Trui-f-

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[] the Applicant -j-n
f-fia legal entityholdieg a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an intcrest.cSVfl/OK" <fUf/ff tfa<CCl&d NoruJV&c/ PdrK-,

OR ⁰ LLC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: Qhl P)ftf-fvn Plittt .farfc >t&0

PsoJivn AAA 07-10$

corn
Telephone:^/ £ Y - 00 Fax: ^>f7~Q>ZY~ 0 ? H Email: bchimf>j^ b*fhA CAfM ■
Name of contact person: QrtftUft &h&mfP~vj

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

Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

ttvMB. j^vxiuruj -for 61 oo N ■ pA^hm Avtxuc

Which City agency, or department is requesting this EDS?_

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

Specification # N<H frfflli fftbt>C and Contract # M * + fcypUtt fafe

Ver. 01-01-32

Page 1 of 13

SECTION R - DISCLO3033 OF 0WN2&BHIF ,lNTS^.iSST5

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

[JYes . [i/ Other (please specify)

{ J Person

f ] Publicly registered business corporation [] Privately held business corporation [] Sole proprietorship i j General partnership j I Limited partnership I^:; Trist

f ' Limited liability company

[ ] Limited liability partnership

( ] Joint venture

IJ Not-for-profit corporation

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

b/o .

tyvmblt fault, m-AYitrj bVfiYrhfr TfUtf-

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

W^J/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 ro such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity ia a general partoesrahip, lirrtlted parmership, Umited 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. NOXiC: 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 ths Disclosing Party. Examples of such an interest inchids shares in a corporation, paiteership interest in a partnership or joint venture,

Page 2 of 13

interest of a member or manager in a limited bability 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 in!? disclosure.

Name Business Address Percentage Interest in the

Disclosing Party

JflU P. Manning 0*£ Jfofch Place /OOf SrthdflcUrM

SECTION m ~£'J3W2$3 SSLATICNSBIPS 'mTZ CITY J5£*3CTEI> 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?

I ] Yes fc^No

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

SECTIC-?! IV -3J2CLC3URS O? SU2CCNT2ACTDR8 AND CTHSR IUZTAIN£B 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 Parry 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 behclf 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 Ra-ationship to Disclosing Party Fees (indicate whether

retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOT 2:

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

not an acceptable response.

(Add sheets if necessary)

1-4 Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entitiss. SECTION V - £JE»T*&lATXOKS

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 obb'gations throughout the contract's term.

Has any person who directly or mdircctly 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 &(xo [ ] No person directly or mdire:tly 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?

HYes []No

FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1 -23, Article ! ("Article F)(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party srJ)znitting this EDS is the Applicant and is doing business with the City, men the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or bas 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, diahoassty or deceit against an officer or employee of the City or any sister agency; and (ii) ise Applicant understands and acknowledges that compliance with Article 1 is a corrtmuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliar.ee tansfrrcne in Article I supersedes some xlve-ye&r 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, nil of those persons or entities identified in Section ll.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, state or local unit of government;

1. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;

are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth ia 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 crirninal 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 ot subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons ot legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");

any "Affiliated Entity' (meaning a person or entity that, drrecdy 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: mterloclririg 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 mcligibiiity of a business entity to do business with federal or state or local government, including the City, using substantially the seme management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or mdrrectfy controls the Contractor, is controlled by it, or, with the Ccatractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any othisr 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 Affiiiated Entity (conectiveiy "Agents").

?sge5of 13

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

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 BLCS 5/33E-4; or (3) any similar offense of any state or of the United States of America mat 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 tho following lists mamtained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the 3ureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), She Disclosing Party must explain below:

Page 6 of 13

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

8. To the best of the Disclosing Party's inowledge 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, r.n employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "no7ie*5-

M)Wj^.

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 ot caused to be given, at any time during the 12-month period preceding the execution date of this ED3, 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 pubb'c, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

11 is K^is not

a "financial institution" as defined in Section 2~32-45S(b) of the Municipal Code.

If the Disclosing Party IS a financial institution, then tha 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 afialiate of s. predatory lender may result in the loss of the privilege of doing business with the City"

If the Disclosing Party is usable 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 nu;ariing of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

In accordance with Section 2-i 56-110 of the Municipal Code: Does any official or employee of the City have a financial interest in fcis or her own name or in the name of any other person or entity in the Matter? /

t j Yes $J[No

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

Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes ox 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 mis Part D.

Doss the Matter involve a City Property Sale?

[ j Yes [ ] No

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

Name Business Address - Nature of Interest

4. The Di8closmg Party further certifies be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please checl: dther 1. cr 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

PsgeSof 13

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

■ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (mcruding 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 ot 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:

S3CTZOW V! - FGagXDmALLY rONDm MATtmS

iiOTS: If ©3 Meiter is fadarJly iaaiieu, complete this Section VL AfSae Maitsr ia ;ist federally tsniei, proceed to Section VD. 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 persona 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 Marten (Add sheets if necessary):

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

Page 9 of 13

The Disclosing Party v/iil submit an updated certification at the end of each calendar quarter in which there occurs any event thai materially affects the accuracy of the statements and raxorrnation set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (f) it is aot an organization described in section 501(cX4) 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 D isclosing Party is the Applicant, the Disclosing Party must obtain certifications equ a?; n 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 Bubmit the following information with their bids or in writing at the outset of negotiations.

Is ths Disclosing Party the Applicant?

[]Yes

If "Yes," answer the three questions below:

Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See CFR Part 6C-2.)

[ j Yes [ j No

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

11 Yes []No

Have you participated ia any previous contracts or aubcoatracts subject to the equal opportunity clause?

□ Yw [JNo

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

Page iO of i3

SZCTlDtf VJI- AC^OWZ^GMRNTS, CONTKACT if?CO.TIPOSATION, COM^ilAWCiB, PSNALTIBS, mSCLCSUEUC

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 procuremsnt, 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.cityofcbicago.org/GBthics. and may also be obtained from the City's Bosrd of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 50610, (312) 744-9660. The Disclosing Party must comply fully wiih 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 3DS 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 *lso authorizes the City to verity 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 ihiB 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. flOTE: With respect to Matters subject to Article I of

Chapter 1-23 of &e Municipal Code (imposing PiSRivLAftSNT INtfLJGDJZLITY for certain specified

offenses), the information provided horein regarding su'gibility 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 aad v/arrants that:_;

Page U of 13

. F.T. The Disclosing Party is not delinquent in the paym

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.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

is oiAin

ihhn Pawning wot- Um&ble rrusi-

(Print or ty^pen^rrre of pislblosing Pajty'f'

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

Signed and sworn to before me on (date)

at \Sl{jfD lh- County, /flfi (sfate).

f\4AtfJ(AJUd ^Ay^l^j Ty^f Notary Public.

Commission expires:_

Page 12 of 13

Cm* OF CHICAGO SCO/JOMIC P (SCLOSUK& STAXBMmZ A2W AS^CAVIT

■VA&sLiAX. mLA-aomm mm jelsgteo c*mr omegas aj«> Dj^AR-iMiLWT ksabs

TSsis App-rttaix i> ta fe» -.oTspIaiat? oa?y by (a) &4 A^itfc*^ sac (b) any Heg'tl -ir<tity 7£iicii lias a dim? c^Tiiirsldj] SKf-arrase5a tin Applicant si>«3t»a:g 7-3percent. It*i j»>¹ io bs caniblete<j *sy pay Isgpiei&tj V7iiiCa 2r?8 oa?y icui-act cwii'salitii irteresi tc iiu> Anpl&i&L

Under Murricipal Code Section 2-134-015, 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 bead. A "farnlial relationship" exists i£ as of the dare this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Parmer thereof is related to ths mayor; any aldermen, 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-brolher or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section H.B.1 .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all man*gars, 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 Disclosreg 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 ary "Applicable Party" or any Spouse or Demesne Partner thereof currently have a "familial rctenonship" with an. elected city ofSriai or departrcant bead?

f }Y

If yes, please identify below (1) the name and title of such person, (2) the none of the legal entity to svbich such person is connected; (3) tho same and title of the ejected chy official or department head to >yhora Buck person has a familial relationship, and (4) the precise nature of uudh farrabai relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND Af I- IDA VIT

SECTION I -- GENERAL INFORMATION

A. Legal norre of the Disclosing Party submitting rhis EDS. Include d/b/a/ if applicable:

VolaW ?Or!t)&% lnl_:

Check ONE of the following three bores:

Indicate whether the Disclosing Party submitting this EDS is: \. [] the Applicant

OR ' /'thiOir WpeOH TO

2. \jfa legal emit/holdwg-a direct or indirect interest in the Applicant. State the legal nan-.;; of the

Applicant in which the Disclosing Party holds an interest:fyftjOf sSM^CS Cfilf.OftV N.0YWQ0C(

OR '^MVitLO

3. [ J a legal entity with a right of control (see Section !i.B !.) State the legal name of the entity in

which the Disclosing Party holds a right of control:

Business address of die Disclosing Party: T'/7l/>/j?/^/ IhUib, Doft flodA, $ ■ H &lt£Y

t wttrt ByHn in

Te\tvboa<itif)(i)f&i'SW- W fvxiwtpKVf WO W Email: f.Mtmaflft V><llU) (0m
Name of contact person: TYCXOr M^irrft#.fi
Federal Employer Identification No. (if you have one): .

Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

fiONB- ~hr\(t\M fV 5700 ^ Mm knmt,. .

Which City agency or department is requesting this EDS? _ &gD

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

Specification # M^:f IfPjf lUhlo _ and Contract # M&t Ifplf (

Ver. 01-OI-1Z

Page I of 13

SECTION ll - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSLNG PARTY

!. Indicate the nature of the Disclosing Party:

[ ] Person f ] Limited liability company

[ ].Publicly registered business corporation [ ] Limited liability parmcrsaip

(If Privately held business corporation [) Joint vesture

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

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

[ ] Limited psjtnciship {) Yes (] No

[ i Trust [ J Other (please specify)

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

M aware

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?

[JYes M"No f ] N/A

3. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

I. List betow the full aarnes and titles of all executive officers. Sad all director of the entity. NOTE: For not-for-profit corporations, also list below all members, if airy, which arc Jega! entities. If there are no such members, write "no members;" For trusts, estates or other similar entities, list below ■the.legal titIeho!dcr(s).

Name Title

3<mpn VutMaYcK p\u(Jhx. SccwMim .TrzaHW

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 as 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 2-15.4-030 of tie Municipal Code of Chicago ("Municipal Code"), the City may Tcquire any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest iu the

, ., Disclosing Party

(U)Jd.h\ii/J &* HfLiifcyJtwctj, Chant! 1^

UUwtls ]iX t-m,bntf foA-ktn

SECTION HI - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ ] Yes p/no

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RE Tit IN ED PARTIES

The Disclosing Party must disclose the name sad business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Parry 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 arc paid solely through the Disclosing Party's regular payroll.

"Lobbyist'' means any person or entity who undertakes to influence tmy legislative or administrative action on behalf of any person or entity other than: (I) a not-for-profit entity, 03 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 admimsttaiive action.

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

Page 3 of 13

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

retained or anticipated Address (subcontractor, attorney, paid or estiraated.)'NOTE;

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

not 82 acceptable response.

(Add sheets if necessary)

here if the Disclosing Party bas not retained, nor expects to rctsia, sny such persons or entities.

SECTION V CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-41S, 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 v/ho directly or indirectly owns 10% or more of the Disclosing Party been declared ia arrearage oirany child support obligations by any Illinois court of competent jurisdiction?

I ] Yes f>^Ne [ j No peison directly or indircclly owns 10% or more of the

Disclosing Party.

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

[ ] Yes [ ] No

B: FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article P'Xwhich the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EOS 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 conyicted.of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit briber}', theft, fraud, forgery, perjury, dishonesty or deeoit 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 Appticant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 bslow.

Page 4 of 13

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

a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily

excluded from any transactions by any federal, stats or local unit of government;

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, cr 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; foTgery; bribery; falsification or destruction of records; making false statements; oi receivingetolen 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 fi ve-ysar period preceding the date of this I3DS, had one or more public transactions f federal, st3te or local) terminate d 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 governmeat, any state, or any other unit of local government.

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

- theDisclosing Psrty.
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 legHl 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 Parry, 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 ofa business entity following the ineligibility ofa business entity to do business with federal or state or local govcirimeni, 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 Parry, 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, aay Contractor or any Affiliated Entity- (collectively "Agents").

Page 5 of 13

Neither the Disclosing Parry, nor any Contracto-, nor any A ffiliated 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, wjtb respect to a Contractor, an Affiliated Entity, or an Affiliated Entity ofa Contractor during the five years before ths date of such Contractor's or Affiliated Entity^ contract or engagement io connection with ths Matter:

1. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
2. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
3. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Cede 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 5/33H-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3).&hy similar offenscofany state or of the United States of America that contains the same elements as the offense of bid-riggirtjr 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 tho U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Parry understands and shall comply with tho applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-! 55 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to aay .of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

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

S. 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 Parly 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").

rv.oirU

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 o'reaosed to be given, at any time during the 12-mobth 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" doss 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 520 per iccipitnt (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check one) (J is fy/isnot

a "financial institution" as defined in Section 2-32^-455(0) of the Municipal Code.

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

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

Page 7 of 13

if the letters "NA," the word "None/' ornoresponsc appears o:n the lines above, it will be conclusively presumed thai the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

In accordance with Section 2-J56-110 of the Manrcipa! Code: Does any official or employee of the City have a financial interest in his or her own name or m the name of any other person or entity in the Matter? /

□ Yes Evj'No

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

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

Does the Matter involve a City Property Safe?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

^tr. 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 BUSINSSS

Please check either l. or.2. below. If the Disclosing Parry checks 2., the Disclosing Party must disclose below or.'in ah aruscbrxient to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

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

^kc Disclosing Parry verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of invest ents 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 staves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the sesrch 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 thenames of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Mutter is ftderHily funded, complete this Section VT If the Matter 1b not federally fondeii, proceed to Section VD. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City arc pot federal funding.

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of]995 who have made lobbying contacts on behalf of the Disclosing P3rty with respect to the Matter: (Add sheets if necessary):

(If no-explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 havc.madc lobbying contacts on bebalf 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 Li Paragraph A.l. above, for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Psriy 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.!. ind A.2. above.
The Disclosing Party certifies that either: (i) it is not aa 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 die Internal Rcvccue 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 ecrtifications equal in form and substance to paragraphs A.l. througb,A.4. above from all subcontractors b*forc it awards any subcontract and the Disclosing P3rry must maintain all sucb subcontractors' certifications for the duration of the Matter and must make such certifications promptly.available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[JYes

If "Yes," answer the three questions below:

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

[ ] Yes []>^J°

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

[J Y« () No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS wjli become pan of any

contract ot 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 thc.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 uransactioos. The full text of these ordinances and a training program is available on

line at www.citvofchtc«i;o.orr;/Etbics, and may also be obtained from tho 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), ii law, or ic equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in omer transactions with the City. Remedies at law for a false state-menl of material fact may mcludeincarccratioa and an award to theCity 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 cf the information provided on this EDS and, any attachments to this EDS maybe made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it nay have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

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

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

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

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

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

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

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

The Disclosing Party represents and warrants that:

Page 11 of 13

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

F.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

(Sign here) (Print ortype name of person signing)

Pwitftnf

(Print or type title of person signing)

Signed and sworn to before me on (date) ° ,

at ST Wzu '&LOxim: CT&gS£»-t (rtatfl.

-- Notary Public.

Commission cxpires:_

Page 12 of 13

I.W.S. Strang NOTARY PUBLIC Templar House, Don Road, St. Keller, Jersey, JEl iAW +44 (0) 1534 500300

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDA\TT 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 » direct ownership Interest !n the Applicant ercccding 7.5 percent It is not to be completed by my 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 Puttier thereof currently has a "fenilial relationship" with any elected city official or department head A 'familial relationship" exists if, as of the dete this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Psrmer 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 nepfcew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister cr half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party-listed in Section ff.B.1 .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members' of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent cwnersb-;? intcrcst.in ths 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 "familid relationship" with an elected city official or-department head?

I ] 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 end title of the elected cityofficial 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 or Chicago

ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

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

Vjjuv hhMwjS Lbc) LimHfd

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

OR , fhout etptOH TO

y^a legal entitynel'Uftg-a direct or indirect interest in the Applicant. State the legal name of the

Applicant in wh:ch the Disclosing Party holds an interest: 'Stfli'S (\hl(,Q6fl) f\/0YW0QCi

or ~" " ' ~'^J fr.rftiio

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party:

dtmu. OhunnrJ 1*1 Mils, TZ

Telcphone/V/V#)/g?y-^- W ?zxlwYt)lZW WO <ft& Email: tyifflMtrf* V>U{A)-(0^
Name of contact person: ^TJtYOr N^WA/)
Federal Employer Identification No. (if you have one): .
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable);

jfOMB- -hnJlm 5700 A/- Mm frvtwt,

Which City agency or department is requesting this EDS?_

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

Specification # M'T Lj)p\l Cdbjo and Contract # Ntf AfPl({ttb(C

Vcr. 01-01-12

Page I of 13

SECTION II DISCLOSURE OF OWNERSHIP INTERESTS

A NATURE OF THE DISCLOSING PARTY

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

[JYes [jNo [ 1 Other (please specify)

1. Indicate the nature of the Disclosing Party: [ ] Person

[ ] Publicly registered business corporation [ ] Privately held business corporation f ] Sole proprietorship {J General partnership [J Limited partnership {] Trust

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

3. For legal entities not organized in the State of Illinois: Has the organiza tion registered to dp business in the Slate of Illinois &s a foreign entjrv?

MfNo

[ 3 Yes

[ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:.

1. Listbelow the foil names nnd titles of all executive cfficjrs and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are lege I 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: Eacb legal entity listed below must submit an EDS on its own behalf.

Name Title

Vo\<M StvttHMi, LTD -seortfy

2. Please provide Ac 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,

interest ofa member or manager in a limited liability company, or interest of a beneficiary ofa 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 fro:;: any applicant which is reasonably intended to achieve full disclosure.

N'jmc Business Address Percentage lntejeat in the

, Disclosing Party

^ M.\t>v, JcvltM, Uo f -

ilEUTE. brf M ftwiaw

SECTION ID BUSINESS RELATIONSHIPS WITH CrfY ELECTED OFFICIALS

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

[ j Yes s/nc

If yes, please identify below the 3ame(s) of scch City elected cfficial(s) and describe such rclationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Parry has retained Or expects to retain in connection witii the Matter, as well as the nature of the relationship, and the tots! 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 unp3id basis, or (2) himself. "Lobbyist" also means any person or entity anypart of whose duties as amemployee of another includes undertaking to influence any legislative or administrative action.

If the Disclosing Party is uncertain whether a disclosure is rebuked 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 Parry Fees (indicate whether

retained or aniicipa'ed Address (subcontractor, attorney, paid or estimated.) NOTE:

to be retained) lobbyist, etc.) "hourly rare" cr "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

[v/iheck here if the Disclosing Parry has not retained, nor expects to retain, any such persons cr entities.

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal-Code Sectior. 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 mors of the Disclosing Party been declared in nrresrcge on any child support obligations by any Illinois court of competent jurisdiction?

[ j Yes £#No r ] No person directly or indirectly owns 10% or more of the

Disclosing Party.

If "Yes," has the person entered into a ceurt-approvcd agreement for payment of all support ov»cd and :-s the person in compliance with that agreement?'

□ Yes f]No

B. FURTHER CERTIFICATIONS

K Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(wbich the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EOS is the Applicant and is doing business with ths 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 ev er been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, freed, 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 lis a continuing requirement for doing business with the City. NOTE: If Article I applios'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 23

2. its Disclosing Parly and, if the Disclosing Party is a legal entity, ali of those persons or entities identified in Section JIB.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 guv-emmem;
have tot, 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;
ere hot presently indicted for, or criminally or civilly charged by, 2 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 CDS. had one or more public transactions (federal, state or Iocs!) terminated for cause or default; and
have not, within a five-year period preceding the date of this FDS, been convicted, adjudged guilty, or found iiablein a civil proceeding, or In any criminal or civil action, including actions concerning environmental violations, institu ted by the City or by the federal government, any srate, or any other unit of local government.

3. The certifications in subparts 3,4 2nd 5,concern:

- the Disclosing Party;
any "Contractor" (meaning any contractor ot subcontractor iised 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");
eny 'Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, wi'Ji 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 busiccJS with federal or state ot local government, including the City, using substantially the same management, ownership, or principals ss the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or, indirectly controls the Contractoryis 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 Enrity 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 Conrxsctor or any Affiliated Entity (collco'ivcly "Agents").

Pigc5of 13

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

bribed or attempted to bribe, or been convicted or adjudged guilty of briber/ or attempting to bribe, a public officer or employes of the City, the State of Illinois, or say sgeacy of the federal government or of any state or local government in the United States of America, m thai-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 cmong 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. ebovs that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-510 {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 rests It of engaging in or being convicted of (1) bid-rigging ib violation of 720 ILCS 5/33B-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United Sra'es of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets, Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List; the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable ruc.uirersents of Chapters 2-55 (Legislative, Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Perry is unable to certify to any of-thc above statements in this Part B (Further Certifications), the Disclosing Parry must explain below:

Page 6 of 13

if ihe letters "NA;" the word "None," or no response appears oit the lines above; it wiil be conclusively presumed that the Disclosmg Party certified to the above statements.

8, To the best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of alleurrent 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 eiestcd.or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").

l,AyPYW_.

9. To the best of the Disclosing Parry'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 rime 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 genera? public, or (ii) food or drink provided in the course of official City business and having a rctii! value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL. INSTITUTION

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

not

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

If the Disclosing Party IS aTmancial 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 ofa predatory lender may result in the loss of the privilege of doing business with the City "

If the Disclosing Psrty 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 Cods, explain here (attach, edditional pages if necessary):

Pige7of 13

If the le"?rs "NA," the word 'None," or no response appears on tie line? 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 tcr-ts that are defined in Chapter.2-136 of the Municipal Code have the same meanings when used in this Part D.

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

[!Yes [v/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 PnrtE.

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 (co)lcct'vely, "City Property Sale"). Compensation for property taken pursuant to ths City's eminent domain powe docs not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City'Properfy Sale?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

4. The Disclosing Parry further certifies that no prohibited Rmtncial interest in the Matter will be acquired by my City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check eiibcr 1. or 2. below. If theDisclosing Party checks 2 the Disclosing Party must disclose below or in an attachment to thi3 EDS all information required by paragraph 2. Failure to

Page 8 of 13

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

y^J. Tec Disclosing Party verifies that the Disclosing Party has searched any and all records of die Disclosing Party and any and ail 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 Parry verifies that, as a result of conducting the search in step 1 above, the.

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

SECTION VI- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing P3ity with respect to the Matter: (Add sheets if necessary);

(If no explanation appears ot 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-Lobbyihg Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosicg Party has not spent and will hot 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 ofa member of Congress, in connection with the award of any federally funded contract, making any federally funded grant cr lean, entering into any cooperative agreement, of to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or.cooperative agreement.

Pegc 9 of 13

The Disclosing Party will submit an updated certification at ths erid 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 Part)' 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 Patty is the Applicant, the Disclosing Party must obtain certifications equal ia form and substance to paragraphs A.I. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Mailer and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL-EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[JYes

If "Yes,'" answer the three questions below:

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

[ J Yes [ };No

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

[JYes f]No

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

[} Yes [ ] No

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

Page 10 of 13

SECTION VH- 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 wfeich this EDS is based.

3. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-15 J of the Municipal Code, impose certain duties and obligations on persons of entities seeking City contract?, work, business, or transections. The full text of these ordinances and a training program is available on line at www.ciryofch:cago.org/Etbics. and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago. IL 60610. (312) 744-9660. Tbc_;DiscIb;:ng Party must comply fully with the applicable ordinances.

If the City determines that any information provided in this EDS is false, incomplete or iniiccKiatc, any contract or otheT agreement ir connection with which it is submitted may be rescinded Ot 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 Parry'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 ths public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments io this FDS may be made available to the public or. 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.Deparrment of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to.ArrJcle I of Chapter 1 -23 of the Municipal Code (imposing PF K MANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.l. The Disclosing Party is 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 not limited to, all water charges, sewer charges, license fees, parkinglickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Parly 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 truc,,accurate and complete as of the date furnisltelTto the City.

(Sign here)

(Print or type name of'person signing)

])\ytcW

(Print or type title o.f person signing)

Signed and sworn to before me on (date)

at gr t*6u£& County, <Tf=is^ (state).

Notary Public.

Commission expircs:_

Page 12 of 13

I.W.S. Strang NOTARY PUBLIC Templar House, Don Road, St. ftelier, Jersey, JE11AW +44 (0) 1534 500300

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY' OFFICIALS AND DEPARTMENT HEADS

This Appcndb: is to be completed only by (a) the Applicant, and (b) any legal entity which has u direct ownership Interest in the Applicant exceeding 7J5perccnt. It is not to be completed byisny legal entity which has only an indirect ownership interest iri the Applicant

Under Municipal Code Section 2:154-015,the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Parr/' 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 tc the mayor, any alderman, the city clerk, the city treasurer or any city department head es spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt cr uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, dsagbter-in-law, stepfather or stepmother, stepson cr stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive ofjtccrsof the Disclosing Party listed in Section U.B.l.a., if the Disclosing Party is a corporation: all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Perry 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 ofa legal entity or any person exercising similar authority.

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

I JYes

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 fam ilial relationsliip, and (4) the precise nature of such familial relationship.

Page 13 of 13

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CITY OF CTJTCAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Ylkuj fhiUih<j$, i, LTD

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

or s-rkixA &peoti -h>

Pfa legal enriry/holdwuL a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: 'St'AiHf *Sui~!('>* fcfafCCtfV NQY'tfOod

■OR * P*rlL_fUC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party; ~Ttft\t>iM ikuUsiDofi flpOli, (fiHol(6Y

a cm'U. Charm f.l Is I find s_f

Telephone^)/^/£?y_-^^. Fax^Y'j)^/ Wff Email: t.Mmanf? wUtV-fW
Name of contact person: JjLCX£tL

Norman

Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

tfVHE -Awflinj fV 5700 fJ- Mm frumi

Which City agency or department is requesting this EDS? H

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

Specification » Nit LP pi I C<lblt> and Contract U M^ ^0>l(Ub(C

Ver. 01-01-12

Page 1 of 13

SECTION - DlSCLOSCR-i Or OWNKRSUiP INTERESTS

A. NATLK.H Of THH DISCLOSING PARTY

i Indicate the nature of the Disclosing Party: S

I J ?er?on '{.flirted luMity wrsamy

[ ] PubUely register:.! bussttiMi ,-3-porauoa [ J I invited liabitiry _?.\rthc:«i?

[ ] Privnialy'■-:(! b"-ir.;<« co-rio:?';^^-! [] Ji>iot venture

[) Sole propr-etorshw [ J Nct-for-pfc!?: eorjwTstfcn

r ] Gcr.erai twitwrstiip (Is the not-for-profit corpwjt'cn a'to ft 501 (:){"?))?

[ j Limit*} psrt.wship (J Yes {J No

[) Trv.it {] Orher (plw»s ipeetfyl

2. For c.-.;tt:rs. ':? stole (or fonr.gr. eounrr.O of incorpsraaon or or>:.:r-i-ar.io-. if spplieebte:

3, For teijs' entities not organ;?:--! in the State of Iliweij: Kss '.be orgaakarion registered to do

business in the State of Illinois as a foreign entity?

,^r ] Yes it =-<!o [ ] N/A

B. IT TK2 DISCLOSING PA STY 15 A LEGAL ENTITY:

1. List beb'-v the full names aid titles of all executive officers and all directors of the entity. NOTE*. For oot-ftfr-profit crrporatioss,, also list bebvy all members, if any, which arc legal cr.trtics. If tier; sr? no saeh miirifccn;, -.vn*c "co members." For t.-u«!j. enisles or other jiritilar entities, lis: fccfow the legal litisboldc:(s).

If the entity is a general partnership, h'ra ted partotnliip, limited liability company, limited liability partnership orjoint venture, list brio-* the r.smc arid tit!" of esc.¹; genera! partne;, managing member, manager or any other person or entity -hat controls the day-to-day management of the Dfjclosinj ?ir:y NOTE: Bach legal eerily listed below rncst submit an EDS on its own behalf.

N'ame Tills

Yihi-vJ ucvAAHh. LTD -SnmftM

Vi id lo Hoicliiniu LaMtlL JoM Mfttfibtr _

Jzt dittUi~~tJ hs~~-r ~~o{ d~~l~~fttfv~~rt

.2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in exesss of 7.5% of ihe Disclosing Party. Example* cf such aa interest include ihaies in 3 corpor.itior., partnership fcuereit in a partnership or join; ventur:.

Pat:c3of 13

interest ofa member or manager in a-limited liability company, or imrrcs! of a beneficiary ofa 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 Dusmess Address Per'centsge Interest in the

Disclosing Party

Vikuj (mup ifinpter m if.Din Uod

hiding LirM &-MtoAfticy, /OP/-

t CMnnrJ UlUHrh ,

, \)2(2T£. kick* Mjjh

SECTION III - BUSINESS RELATIONSHIPS WITH. CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-J56 of the Municipal Code, with any City elected officiel in the 12 months before the date this EDS is signed?

[ j Yes

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

SECTION" IV DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

"Lobbyist" means any person oi entity who undertakes to influence any legislative oi administrative action on behalf of any person or entity ether 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 sr. employee of another includes undertaking to influence any legislative or administrative action.

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

Page 3 of 13

Name (indicate whether Business Relationship lb Disclosing Parry Fees (indicate whether

retained or anticipated Address (subcontractor, attorney; p3id or estimated.) NOTE:

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

r.ot an acceptable responsr.

(Add sheets if necessary) fjfciie.ck here if'.ht

the Disclosing Party has not retained, nor expects to rctiiti. any such persons or intities.

SECTION V - CERTIFICATIONS

A. CPURTORDERBD CHILD SUPPORT COMPUANCE

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 thrcnghout the contract's term.

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

[ ] Yes f/fNo [ ] No person directly or indirectly Owns 10% or more of the

Disclosing Parry.

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?

f 1 Yes [] No

Q. FURTHER CERTIFICATIONS

I. Pursuant to Municipal Code Chapter 1-23, Article! ("Article I")(whkh 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 tie Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or nas 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,.dishpncsty 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 Psrty and, if the Disclosing Pa-rvy is a legal entity, all of tboso persons cr entities identified in Section 31.B.I. of this EDS:

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered 3gainst them in connection with: obtaining, attempting to obtain, or performing a pubiic (federal, state or local) transactor, 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 tiiis EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and

c. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.

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

the Disclosing Party;

any "Contractor" (meaning any contractor Or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons cr 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 ofa business entity following the ineligibility ofa business entity to do business with federal or state or local government, including the City, using substantially the seme management, ownership, or principals as the ineligiblecnlity); 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 endcr 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 Parry, any Contractor of 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

■.'either the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either ths 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 ofa Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection wjta the Matter:

bribed cr attempted to bribe, or been convicted or adjudged guilty of briber)' or attempting to bribe, s public officer or employee of the City, the State of fllinois, or any agency of the federal government or of 3ny state or local government in the United States of America, in that officer's oi employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, ot 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
mode 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 aay of their employees, officials, agents or partners, js barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging.in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any simitar offense of any state or of the United States of America that contains the same elements es the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U:S. Department of the Treasury or the. Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specialty Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and ths Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is anabie to certify to any of the above statements iii this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

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

8. To the best of the Disclosing Parry's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, atatiy 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 "NVA" or "none'*).

9. To the best of rhe 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-rj)onth 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, cr (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, plc.ise s'so bst the name of the City recipient.

" A/?yn ~

C. CERTIFICA HON OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Parr/ certifies that the Disclosing Farty (check one)

[ ] is f^is not

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

If the Disclosing Party IS a financial instihitionthen the Disclosing Party pledges:

"We are not and will notbecome a pred3tory 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;defmed in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predator)' lender may result in the loss of the privilege of doing business with the City."

P3ge 7 of 13

If the Itturs "MA.," the word "None," or no response appears on the lines above, it will be conclusively presumed thai the Disclosing Party certified to the above stiterncets.

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are deftned'in Chapter 2-156 of the Municipal Code have As same meanings-when used in this Pait D.

]. lu accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his 07 her own name or in the name of any other person or

entity in the Matter? [JYes

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., pro-eed to Part E.

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

Does the Matter involve a City Property Sale?

i J Yes [ 1 No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13.

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

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

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

Disclosing Party has found records of investments or profits from slavery or slaveholder-insurance policies. The Disclosing Psxty 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: irthe 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 procsrds of debt obligations of the City are not federal funding.

A. CERT I i"'CAT10N REGARDING LOBBYING

(If rio 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 net spent and will not expend any federelly appropriated funds to pay any person or entity, listed in Paragraph A.I. above for Sis or her lobbying activities or to pay any person or entity to influence or attempt to influence 3n officer or employee of any agency, as defined by-applicable federal law, a member of Congress, an officer or employs- of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend; or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

The Disclosing Party will submit an updated certification a: 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 cither: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1980; oi (ii) it is an organization described in section 501(cX4) of the Internal Revenue Code of I9S6 but has not engaged and will not engage is "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party rn^st 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 maiotain all such subcontractors' certifications for the duration of the Matter and must maJce 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 ths following information with their bids or fn writing at the outset of negotiations.

Is the Disclosing Party the Applicant?

[ J Yes

If "Yes," answetr the three questions below:

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

[]Ycs lJNo

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

□.Yes " []No

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

[ J Yes [ ] No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, 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.

D. The City's Governmental Ethics .md Campaign Financing Ordinances, Chapters 2-156 end 2-164 of the Municipal 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 i3 available on line at www.cir/ofchicseo.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 Parry must comply fatly with the applicable ordinances.

If the City determines that any'information provided in this EDS is false, inccreplsfe or inaccurate, any contract or other agreement in connection with which it is subtnitted 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 Mutter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies 3t 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 poiicy to make this document available to the public on its Inrcrnet site and/or upon request. Some or all of the information provided on this EDS and any attachments to thU EDS maybe made available to the public on the Internet, in response u? 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 3nd also authorizes,the City to verify me 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 sabject to Article I of

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

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

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

The Disclosing Party represents and warrants that:

Page II of 13

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.

NO TF: 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

Trtvov Is Novrin

(Print or type name of person signing)

(Print or type title of person signing)

Signed and sworn to before me on (date) 3 ° Mfr*1 2£> >3 at Sf B-&-0fc Cetmty, T&tSfa (state).

Commission expires:

Page 12 of 13

I.W.S. Strang NOTARY PUBLIC Templar House, Don Road, St. Helier,

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 fa) the Applicant, and (b) any legal-entity which fm a direct ownership Interest in the Applicant exceeding 7.5 percent. It Is not to be completed by any tegp.l entity which' has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "'familial relationship" exists if, as of the date this EDS, is signed,'the Disclosing Party or any "Applicable Parry''' 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, daucbtcr-m-!,T", stepfather or stepmothsT, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

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

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

[ ] Yes

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

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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

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

VlhuL b'wjLf fhldwiS l.jmihfJ

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [ } the Applicant

or ^■fhVUt tYpClfcw

legal enlilyMiolcfeg-a direct or indirect interest in the Applicant. State the legal n;;;ne of the Applicant in which the Disclosing Party holds an interest: Sctyor <SurfCS t2,hl(.QtyV NoYtfQod

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: ~T(/m!>!(lr lkU(b-tDofi flfHtj, (It - H' t'li&Y

iltWU. Ohanml Islands, U~£te rk v Orr&d BytH in

Tclephone/'/^]/^'/^ fO0 Fas/yM^/ ^0 j^O Email: j HOYftltint⁷ V" UuJ ' (0
Name of contact person: TrtYOr /Y ^"-771/7

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

Brief description of contract, transaction ot other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

/W£ -Wlrij fV 5700 H- Mm frHMt,

Which City agency or department is requesting this EDS?

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

Specification * Net LpfijjI Mbit, and Contract # M&i Afjp!(Ub(C

Yer.01-01-U

Page 1 of 13

SKCTION I I - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

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

[ ] Yes F ] No

f ] Other (please .specify)

1. Indicate the nature of the Disclosing Party: ( ] Person

[ j Publicly registered business corporation [ ] Privately held business corporation [ J Sole proprietorship { I General [\irtntrihip [ ] Limited p.?rtr-rshir. [ j Trust

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

'J&tfyJ (Lh k Ii I an tit)

For legal entities no! organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as 8 foreign entity?

[ ] Yes fijXff^ [ ] N/A

3. IF THE DISCLOSING PARTY IS A LEGAL ENTITY: .

I. List below the full mimes' and titles of all executive officers and all director;, of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If mere arc no such members, write "no merribcrs." For trusts, estates or other similar entities, list below the legal rjt!ehoW:r(s).

If the entity is a,general partnership, limited partnership, limited liability company, limited liability partnership or join: 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 !er;ai entity listed below tmi3t submit an EDS on its own behalf.

Title

Name

<Stwti*rM

SecnHotf-fr, ltd

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

Page 2 of 13

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

Name Business Address Percentage Interest in the

Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[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

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 {iridic.--- vjtrrjscr S'tsinsss Relationship to Dt'ciosi.-.g Pany Pecs (indiccR «-J;c*ii?r

rtts:r.ed cr armtrpat.-d Aid; "t iviovmrzciz-. av.rrrty, paii or estimcted.) NOTE;

to be rw.-.ir lobbyist, «c 1 ''ho ir!y rite" \r b J." is

tot an ac.*s_-t*btc -irsssnse.

.'Add Jlwj if■-■sry >

Vjtbecfc here if the Disclosing Party ha'} n<5: retained, aor ?x;«»-:< to retails, wy «:!: person- or *n>ilic%.

SECTION V - CERTIFICATION'S

A. COURT-ORE-3 iifc'D CWi.D SUPPORT COMPLIANCE

Urrfer Municipal Code Section 2-95-415, substantia! ov/aers of &u.*ir.e:s entitse* cosr/jct with the City t.vj; ?c.~3:a in compliance with their child support obligations throughout the centJaM's terr.i.

Has ar.y pcrsoc who directly or indirectly owns )0% cr ore of the Disclosing ?ar*y been declared in arrearage ert any child support obligations by any lltiaois court of competent jufi-id-.chos?

[) Yes. llrfZ f J No person directly or a«j»«fly owns 10% vr T.crr ->f the

Disclosing Party.

If "Yes," has the perron entered into a court-approved agrcrnerit for payrr,;nt of ail support owed and .'s the prr;oB in compliaara with that agreement?

r 1 Y" CINo

3. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23. Article [ ("Article !"5{which the Awpifeam should coKtilt for defined terms {e.g., "dofcg bnsiccsi^H) acd legal ptsjuirsmeats,). if the Disclosing -Party submitting this (IDS is '-he Applicant and is doing business with fts City, then the Disclosing Party aeru'fics as follows: (t) neither the Applicant cor any controlling person is cuirecrly :nd:ct:d or charged wi, or ha¹; admitted gnilt of, or'has ever been convicted of, or placed under super/isios for, aay critnUisl offen.se involving actual, attempted, or cwsplraey to commit briber,-, theft, ftxti. forg:ry, perjury, dishonesty or decsit agates', aa officer 01 employes of the City ot aay eis'.cr ajettcy; and (ii) the Applicant understand* and acknowledges that crjfroitance with Article I is a continuing requirement fcr doing business with the City. NOTE: If Artiela I applies to the Applicant, the pcrmar.cn- cosipb'ancs timeframe :n Article I supersedes some fivs-y?-sr compliance timcfrstnes ia certitrcaticrs 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, ail of these persons cr entities identified in Section, II.3.1. o: 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, act, within a five-year period preceding tie date of this EDS, been convicted ofa crtrniriai offense, adjudged guilty, or had a civil judgment rendered against thcrn in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a p-tblic transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsiftcation.or destruction of records; making false statements; or receiving stolen property;
arc not presently indicted for, or crimiaslly or civilly charged by, a governments! '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 mere public transactions (federal, state or locaD terminated for cause or default; and

c. have not, within a five-year period preceding the dat? 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 a ay other unit of local government.

3. The'certifications iti subparts 3, 4 and 5 concern:

> the Disclosing Party;

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

r any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Parry, is controlled by the Disclosing Party, or is, -with the Disclosing Parry, itadcr 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 3 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 Affiiiited Entity or arty otber 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 Putty, nor any Contractor, nor any Affiliated Eatity of cither the Disclosing Party crany Contractor nor any A gents have; during the five years before the dare this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the fr-s years before the date of such Contractors or Affiliated Entity's contract or engagement in connection with the Matter

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

Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any tm.it of sure or local government as a result of engaging in or being convicted of (1) bid-rigtring 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 «s the offense of bid-rigging or bid-rotating.
Neither the Disclosing Parry 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 sad the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2 -55 (Legislative Inspector General), 2-56 (Inspector Genera!) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Part)'must explain below:

Page 6 of 13

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

8. To the best of the Disclosing Parry'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-montli period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with. ^viN/A" or "note'').

Nont"

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete lis! of all gifts that the Disclosing Parry has given or caused to be given, at any time during the !2jmonth 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 riot include', (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or 'r.cac"). As to any gift listed below, please also list the name of the City recipient.

Hum,

C_: CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION :. The Disclosing Party certifies that the Disclosing Party (check one)

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

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

"V/e 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 Sccrion.2-32-45S(b) of the Municipal Code) is a predatory lender wiibiu the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if accessary):

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lraes 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.

I. In accordance with Section 2-156-110 of the Municipal Code; Dees say 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? S

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

Unless sold pursuant to a process of competiti ve 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 zhy 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 Pan D.

Does the Matter involve a C'ty Property- Sale?

[) Yes [ j No

If you checked "Yes" to Item D.l., provide the, names and business addresses of the City officials or employees having such rmerest 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 cr employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Ma'.l:r voidable by the City.

I. The Disclosing Party verifies that the Disclosing Party has searched ,-my end all records of

the Disclosing Party and 3ny and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (Including fr.scrooce policies issued to slaveholders that provided coverage for damage to or injury or death of their slave.-), 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

Disclosiog 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 dosenbed in those records:

SECTION VT - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If ths Matter is ferler-illy funded, complete this Section VI. If the Matter is not federally fended, proceed to Section VU. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt oblations of the City are not federal funding.

A. CERTIFICATION REGARDING LOB 3 YIN G

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

(If no explanation appears or begins on the lices above, cr if the letters "N A" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party mesns that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party s;jth respect to the Matter.)

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

Page 9 of 13

The: Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the.Internal Revenue Code of 1936 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 Parly must maintain all such subcontractors' certifications for the duration of the Matte; and must make such certifications promptly available to the City sport .request.

3. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

H the Matter is federally fended, federal regulations require the Applicant and all proposed subcontractors to submit etc following information with their bids or in writing at the cutset of negotiations.,

;s the Disclosing Party ths Applicant?

If "Yes," answer the three questions below:

Have you developed and do you have oa Die affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Pari 60-2 )

[ ] Yes [ ] No

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

[ J Yes [ ] No

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

[ ] Yes ■[ ] No

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

Page 10 of 13

SECTION vn - 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 pan of any contract or other agreement betv-'cen the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements lo 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 cn 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, worfc, business, or transactions. The full text of these ordinances and a training program is available on line at www.cift'ofchic3gu.or<t/Etbics. and nay also be obtained from the City's Board of Ethics. 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 7-14-9660. 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 resc inded or void), at law, cr in equity, including terminating the Disclosing Patty's participation in the Matter and/or declining to allow the Disclosing Party to participate iti other transactions wirti the City. P.cmedies at law for a false statement of material fact may include Incarceration and an award to the City cf treble damages.
It is the City's policy to make this document available to the public on its Internet site aud-'or upon requsst. 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 lo 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 cn the Matter. If the Matter is a

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

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

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

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

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

Thc.Disclosi.-ig Party represents and warrants that:

Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, hor 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 rf 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 theDisclosing 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 te*thc City.

Lrnn'H

Trevor L-fynmatf

(Print or type name of person signing)

Qirtutvy

(Print or type title of person signing)

3o Mftl 1ol3

Signed and sworn to before me on (date)

. - Notary Public.

Commission expires:_

Paee 12 of 13

I.W.S. Strang NOTARY PUBLIC Templar House, Don Road, St. Helier. Jersey, JE1 1AW +44 (0) 1534 500300

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 fntlir«ct<siYnership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Parry must disclose whether such Disclosing Party or ar.y ''Applicable Part/' or any Spouse or Domestic Partner thereof currcatly 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 ar.y Spouse or Domestic Partner thereof is related to the mayor, uhy alderman, the city clerk, the city treasurer cr 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, fathcr-m-law, mother-in-law, ien-in-!aw, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section B-B.l.a., if the Disclosing Party is a corporation,- all partners of the Disclosing Party, if the Disclosing Party is a general 'partnership: all general partners arid limited partners of the"Disclosing Party, if trie 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 ofa legal entity or any person exercising similar authority.

Does the Disclosing Part)- or any "Applicable Party" Or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city.cffieial or department head?

[ JYes

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 departraentbead to whom such person has a familial relationship,.and (4) the precise nsture-of such familial relationship.

Page 13 of 1.3

OFFICE OF THE MAYOR

CITY OF CHICAGO

RAHM EMANUEL

MAYOR

June 26, 2013

TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO

Ladies and Gentlemen:

At the request of the Commissioner of Housing and Economic Development, I transmit herewith an ordinance authorizing the execution of a loan agreement for Senior Suites Chicago.

Your favorable consideration of this ordinance will be appreciated.

Very truly yours,

Mayor

CHICAGO July 24, 2013 To the President and Members of the City Council: Your Committee on Finance having had under consideration

A communication recommending a proposed ordinance concerning the authority to enter into and execute a Loan Agreement for Senior Suites Chicago Norwood Park, LLC.

02013-4978

$3,400,000

Amount of Loan not to exceed:

Having had the same under advisement, begs leave to report and recommend that your Honorable Body pass the proposed Ordinance Transmitted Herewith

(a (viva voce vote

dissenting vote(s)7

This recommendation was concurred in by

of members of the committee with

Respectfully submitted

Chairman

Legislation Text

Legislation Details

Legislation Details (With Text)