This record contains private information, which has been redacted from public viewing.
Record #: O2013-5512   
Type: Ordinance Status: Passed
Intro date: 7/24/2013 Current Controlling Legislative Body: Committee on Zoning, Landmarks and Building Standards
Final action: 9/11/2013
Title: Zoning Reclassification Map No.7-F at 2417-2433 N Clark St - App No. 17782
Sponsors: Misc. Transmittal
Topic: ZONING RECLASSIFICATIONS - Map No. 7-F
Attachments: 1. O2013-5512.pdf
ORDINANCE
 
 
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
 
SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all the B3-2 Community Shopping District symbols and indications as shown on Map No.7-F in the area bounded by
 
 
beginning at a line 99.95 feet southeast of and parallel to West Arlington Place; a line 215 feet northeast of and parallel to North Clark Street; a line 202 feet southeast of and parallel to West Arlington Place; a line from a point 202 feet southeast of West Arlington Place and 230.85 feet northeast of and perpendicular to North Clark Street; to a point, 303.77 feet southeast of West Arlington Place and 211.7 feet northeast and perpendicular to North Clark Street; a line 303.77 feet southeast of and parallel to West Arlington Place; and North Clark Street (ToB),
 
to those of a Bl-2 Neighborhood Shopping District and a corresponding uses district is hereby established in the area above described.
 
SECTION 2. This ordinance shall be in force and effect from and after its passage and due publication.
 
Common address of property:
 
 
 
 
2417-2433 North Clark Street
 
 
-tt Inn 8-l
 
 
 
CITY OF CHICAGO
 
APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE
  1. ADDRESS of the property Applicant is seeking to rezone:
  2.       2417-33 N Clark Street      
  3. Ward Number that property is located in: 43      
3.      APPLICANT      GMS Clark. LLC      
ADDRESS      500 Elmwood Avenue      
CITY Wilmette      STATE        Illinois      ZIP CODE 60091      
PHONE        847-521-8712 CONTACT PERSON      Semir D. Sirazi      
  1. Is the Applicant the owner of the property? YES   X       NO      If the
Applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the applicant to proceed.
 
OWNER      
ADDRESS      
CITY      STATE      ZIP CODE      
PHONE      CONTACT PERSON      
  1. If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:
ATTORNEY      Thomas S. Moore      
ADDRESS    111 W Washington Suite 1100      CITY Chicago      
CITY Chicago      STATE        IL      ZIP CODE 60602      
PHONE      312-251-1500      FAX 312-251-1500
 
 
6.      If the applicant is a legal entity (Corporation, LLC, Partnership, Etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements.
 
 
GMS Investments LP
  1. On what date did the owner acquire legal title to the subject property? 5/22/12
    1. Has the present owner previously rezoned this property? If Yes, when?
      Yes, 1/17/13 to the current zone.      
  1. Present Zoning District      B3-2      Proposed Zoning District Bl-2      
  2. Lot size in square feet (or dimensions?)      44,491 Sq. Ft.      
  3. Current Use of the property 2-story brick building with 44.491 sq. ft. of retail shops and restaurant on the first floor, & indoor parking behind the retail spaces & on the second floor.
  4. Reason for rezoning the subject property: New tenant opened 4.270 sq. ft. restaurant, now as promised property is being down zoned back to the original Bl-2 Zoning District.
  5. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)
2-story brick building with 44,491 sq. ft of retail shops and restaurant (4.270 sq ft) on the
first floor with no designated parking, indoor parking behind the retail shops and on the
second floor.             
14. On May 14 , 2007, the Chicago City Council passed the affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information).
 
YES
 
NO      X
 
COUNTY OF COOK STATE OF ILLINOIS
 
Semir D. Sirazi
 
 
being first duly sworn on oath, states that all of the above
 
Signature of Applicant
statements and the statements contained in the documents submitted herewith are true and correct.
 
Subscribed and /lay of
Notary Public
Sivvorn to before me this .20 13.
 
 
OFFICIAL SEAL HEATHER HASENMILLER Notary Public - State of Illinois My Commission Expires Nov 13, 2015
 
For Office Use Only
 
 
 
 
 
 
Date of Introduction: File Number: Ward:
 
'Air' fi-l.::".r"1)-' Stoni:?' ill -V.v'
cl0\ ',r vo'1 •'■
 
Anderson & Moore, p.c.
Attorneys at Law 111 West Washington Street, Sl jtk 1720 Chicago. Illinois 60602
 
Thomas S. Mooke Ja.nk F. Anderson
Tei.kphone (3121 251-1500 Facsimilk (3121 251-1509
 
 
 
 
 
 
July 24, 2013
 
 
 
To Property Owner or Resident:
 
In accordance with requirements for an Amendment to the Chicago Zoning Ordinance, specifically Section 17-13-0107, please be informed that on or about July 24, 2013, the undersigned will file an application for a change in zoning from B3-2 to Bl-2 on behalf the applicant, GMS Clark, LLC for the property located at 2417-33 N Clark Street.
 
The applicant has a tenant that opened a 4,270 sq. ft. restaurant on the first floor in an existing 2-story brick building with 44,491 sq. ft of retail shops on the first floor with no designated parking, indoor parking behind the retail shops and on the second floor. The new restaurant required a B3-2 Zoning District, now the applicant as promised is down zoning back to its original Bl-2 Zoning District.
 
The owner and applicant of the property is GMS Clark, LLC whose business address is 500 Elmwood Avenue; Wilmette, IL 60091. You can reach Semir Sirazi at 847-521-8712 if you have any questions.
 
I am the attorney for the applicant and can be reached at the above number if you have any questions.
 
Thomas S.\Moore
 
Please note the applicant is not seeking to rezone or purchase your property. The applicant is required by law to send this notice because you own property within 250 feet of the property to be rezoned.
 
TSM:hah
W:\FORMS\Zoning Forms\Zoning Changc\NeighborLtr.wpd
 
"WRITTEN NOTICE" FORM OF AFFIDAVIT (Section 17-13-0107)
 
 
 
July 24, 2013
 
Honorable Daniel Solis Chairman, Committee on Zoning 121 North LaSalle Street Room 304, City Hall Chicago, Illinois 60602
 
_, being first duly
 
Thomas S. Moore
 
 
The undersigned,      
sworn on oath, deposes and says the following:
 
 
The undersigned certifies that he has complied with the requirements of Sec. 17-13-0107, of the Chicago Zoning Ordinance, by sending written notice to such owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said "written notice" was sent by First Class U.S. Mail, no more than 30 days before filing the application.
 
The undersigned certifies that the notice contained the address of the property sought to be
rezoned; a statement of the intended use of the property; the name and address of the applicant;
the name and address of the owner; and a statement that the applicant intends to file the
application for a change in zoning on approximately      July 24, 2013.
 
OFFICIAL SEAL HEATHER HASENMILLER Notary Public - State of Illinois My Commission Expires Nov 13, 2015
 
The undersigned certifies that the applicant has made and bona fide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be_seryed.
Subscribed and Sworn to before rhe this^^fldayof >y>&
 
Notary Public
W:\FORMS\Zoning Forms\Zoning Change\FormAff 11.9-3.1 wpd
 
 
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -GENERAL INFORMATION
A. Legal name of Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
      GMS Investment LP      
Check ONE of the following three boxes:
 
Indicate whether Disclosing Party submitting this EDS is:
  1. [X] the Applicant
OR
  1. [ J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which Disclosing Party holds an interest:      
OR
  1. [ ] a specified legal entity with a right of control (see Section II.B.l .b) State the legal name of the
entity in which Disclosing Party holds a right of control:      
 
B. Business address of Disclosing Party:       500 Elmwood Avenue      
Wilmette. IL 60091      
  1. Telephone:      847-251-8712      Fax:      Email_      
  2. Name of contact person: Semir D. Sirazi      
  3. Federal Employer Identification No. (if you have one):      
  4. Brief description of contract, transition or other undertaking (referred lo below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
 
      Zoning Chantie-2417-33 N Clark Street      .
 
 
G. Which City agency or department is requesting this EDS? Deptof Housina & Economic Development
Bureau of Planning & Zoning If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
 
Specification #      and Contract #      
 
Ver. 01-01-12
 
 
 
Page 1 of 13
 
 
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
 
A. NATURE OF DISCLOSING PARTY
[ ] Limited liability company* [ ] Limited liability partnership* [ ] Joint venture* [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes      [ ] No
[ ] Other (please specify)
 
1.  Indicate the nature of the Disclosing Party [ ] Person
[ ] Publicly registered business corporation [ ] Privately held business corporation [ ] Sole proprietorship [ ] General partnership* [X] Limited partnership* [ ] Trust
♦Note B. I .b below
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: I las the organization registered to do business in the State of Illinois as a foreign entity?
 
[ ] Yes      [ ] No      [XJ N/A
 
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
 
1.     List below the full names and title 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
Semir D. Sirazi Irrevocable "Trust       Member      
Semir D. Sirazi Revocable Trust      Member      
 
 
 
 
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,
 
 
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 parly
Semir D. Sirazi Irrevocable Trust     500 Elm wood Avenue: Wilmette. IL 60091      95%      
Semir D. Sirazi Revocable Trust      500 Elm wood Avenue: Wilmetle. IL 60091      5%      
 
 
 
 
SECTION HI - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
 
Has the Disclosing Parly has 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      [X] 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 & 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 arc 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 Cily 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)      "hourlyrate'' or "t.b.d." is
not an acceptable response.
 
Anderson & Moore-Attorney 1 11 W Washington Ste 1100: Chicago. IL 60602    Estimated to be      
      $5,000.00      
 
 
(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
  1. 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 term of the contract.
 
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      [ X] No      [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
 
If "Yes,1" has the person entered into a court-approved agreement for payment of all support owned and is the person in compliance with that agreement?
 
[ ] Yes      | | No
  1. FURTHER CERTIFICATIONS
 
1.  Pursuant lo 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 the EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neiiher the Applicant nor any controlling person is currently indicated 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 live-year compliance timeframes in certification 2 and 3 below.
 
Page 4 of 13
 
  1. 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:
  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 that 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 charges 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 transaction (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 stale, or any other unit of local government.
    1. 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 any 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, w ithout 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 Cily, 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 ihe direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
 
 
Page 5 of 13
 
 
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
 
a.  . bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United Stated of America, in that officer's or employee's official capacity:
 
b    agreed or colluded with other bidders, or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
    1. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct: or
  2. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
  1. 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 Stated of America that contains the same elements as the offense of bid-rigging or bid-rotating.
  2. 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 Lists, the Unverified List, the Entity List and the Debarred List.
  3. 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.
  4. lf 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:
N/A       
 
 
 
 
 
 
Page 6 of 13
 
 
If the letters "NA." the word "None," or no response appears on the lines above, il 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'*).
      N/A      
 
 
 
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of ail gifts that the Disclosing Party has given or caused lo be given, at any time during the 12-monlh 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 non, indicate with a "N/A" or "none"). As to any gift listed below, please also lisl the name of the City recipient.
      Jsi/A      
 
 
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
  1. The Disclosing Party certifies that the Disclosing Party (check one)
f ] is      [X] is not
a "financial institution'" as defined in Section 2-32-455(b) of the Municipal Code.
  1. 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 of 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.
  1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[] Yes [XJNo
 
NOTE:  If you checked "Yes" to Item D. I , proceed to Items D.2. and D.3. lf you checked "No" to Item D.l., proceed to Part E.
  1. 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
  1. If you checked "Yes" to Item D. 1., provide the names and business addresses of the City officials or employees having such interest and identify 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 lo 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 verities that the Disclosing Party has searched any and all records of
the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery, or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provide coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
 
      2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
 
 
 
 
 
 
SECTION VI - CERTIFICATIONS FOR FEDERALLY-FUNDED MATTERS
 
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI. tax credits allowed by the City and proceeds of debt obligations of the City are not federal funding.
 
A. CERTIFICATION REGARDING LOBBYING
 
I.  List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: ( Add sheets as necessary):
 
 
 
 
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the work "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 lo influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify and federally funded contract, grant, loan, or cooperative agreement.
 
 
Page 9 of 13
 
  1. 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.
  2. 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".
  3. lf the Disclosing Party is the applicant, ihe 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
 
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[]Yes      [1 No
If "Yes," answer the three questions below:
  1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2).
[ ]  Yes      | | No
  1. 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      [f No
  1. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
| I 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 understand and agrees that:
  1. 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 ot her act ion 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.
  2. 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.
  1. 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.
  2. 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 verif y the accuracy of any information submitted in this EDS.
  3. 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 Serv ices, 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 INTELLIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
 
The Disclosing Party represents and warrants that:
 
F.l.    The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Parly 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 on the U. S. E.P.A. on the federal Elxcluded Parties List System ("EPFS) 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. I. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that docs not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
 
NOTE:  If the Disclosing Party cannot certify as to any of the items in F. 1 F.2. or F.3. above, an explanatory statement must be attached to this EDS.
 
 
CERTIFICATION
 
Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
 
 
GMS Investment LP
(Print or type name of Disclosing Party)
 
 
 
By:
(Sign here) Semir D. Sirazai
(Print or type name of person signing)
 
Member      
(Print or type title of person signing)
inois.
 
Signed and sworn to before me on (date)      *7 /
at Cool*
Commission expirtj ;:
. Notary Public —     —        — —■
-erriciAL seal-
HEATHER HASENMILLER » Notary Public - State of Illinois i My Commission Expires Nov p^glf"} 0 I
 
 
 
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
 
 
 
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
 
 
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
 
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Part} "" 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, by blood or adoption, to the mayor, any alderman, the city clerk, the city treasurer, or any city department head as parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, fathcr-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 Part" means (1) all corporate officers of the Disclosing Party, 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 member 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 (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.
 
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -GENERAL INFORMATION
A. Legal name of Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
GMS Clark. LLC      
Check ONE of the following three boxes:
 
Indicate whether Disclosing Party submitting this EDS is:
  1. [X] the Applicant
OR
  1. [ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which Disclosing Party holds an interest:      
OR
  1. [ ] a specified legal entity with a right of control (see Section II.B.l .b) State the legal name of the
entity in which Disclosing Party holds a right of control:      
  1. Business address of Disclosing Party:       500 Elmwood Avenue      
Wilmette. 11,60091      
  1. Telephone:      847-251-8712      Fax:      Email      
  2. Name of contact person: Semir D. Sirazi      
  3. Federal Employer Identification No. (if you have one):      
  4. Brief description of contract, transition or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
 
      Zoning Chanee-2417-33 N Clark Street      
 
 
G. Which City agency or department is requesting this EDS? Dept of Housing & Economic Development
Bureau of Planning & Zoning If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
 
Specification #      and Contract #      
 
Ver. 01-01-12
 
 
 
Page 1 of 13
 
 
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
 
A. NATURE OF 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
 
[X] Limited liability company*
[ ] Limited liability partnership*
[ ] Joint venture*
[ ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes      [ J No
[ | Other (please specify)
 
 
*Note B. I .b below
 
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?
 
[JYes
□ No
 
[X] N/A
 
 
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
 
1.    List below the full names and title 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
GMS Investment LP      Memmber      
 
 
 
 
 
 
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
GMS Investment LP      500 Elmwood Avenue: Wilmette. IL 60091      100%
 
 
 
 
 
 
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
 
Has the Disclosing Party has 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      [X] 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 & 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.
 
 
 
 
 
 
 
 
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)      lobby ist, etc)      "hourlyrate" or "t.b.d." is
not an acceptable response.
 
Anderson & Moore-Attorney 111 W Washington Ste 1100; Chicago, IL 60602    Estimated to be      
      $5,000.00      
 
 
(Add sheets if necessary)
[ ] Check here if the Disc losing party has not retained, nor expects to retain, any such persons or entities. SECTION V -CERTIFICATIONS
  1. 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 term of the contract.
 
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      [X] 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 owned and is the person in compliance with that agreement?
 
[ ] Yes      [ ] No
  1. FURTHER CERTIFICATIONS
 
I. 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 the 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 indicated 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 certification 2 and 3 below.
 
Page 4 of 13
 
 
2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B. 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 that 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 charges 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 transaction (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.
 
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 any 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:
 
a.   bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United Stated of America, in that officer's or employee's official capacity;
 
b   agreed or colluded with other bidders, or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
    1. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
  2. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
  1. 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 Stated of America that contains the same elements as the offense of bid-rigging or bid-rotating.
  2. 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 Lists, the Unverified List, the Entity List and the Debarred List.
  3. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
 
7.      If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A      
 
 
 
 
 
 
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 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").
__      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 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 non, indicate
with a "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
      N/A      
 
 
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
  1. 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.
  1. lf 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 of 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.
  1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[] Yes [X]No
 
NOTE: If you checked "Yes" to Item D. 1 proceed to Items D.2. and D.3. If you checked "No" to Item D. 1., proceed to Part E.
  1. 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
  1. If you checked "Yes" to Item D. 1., provide the names and business addresses of the City officials or employees having such interest and identify 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 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 provide 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 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 allowed 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 as necessary):
 
 
 
 
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the work "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. 1. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify and federally funded contract, grant, loan, or cooperative agreement.
 
 
Page 9 of 13
 
  1. 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.
  2. 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".
  3. If the Disclosing Party is the applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A. 1. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
 
 
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
 
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[]Yes      [] No
If "Yes," answer the three questions below:
  1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2).
[] Yes      [] No
  1. 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
  1. 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 understand and agrees that:
  1. 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.
  2. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
 
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
  1. 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.
  2. 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.
  3. 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 lo Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
 
The Disclosing Party represents and warrants that:
 
 
 
 
Page 11 of 13
 
F. 1.    The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
 
F.2.    If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility on 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: (I) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
 
 
GMS Clark. LLC
(Print or type name of Disclosing Party)
 
By:
 
 
Semir D. Sirazai
(Print or type name of person signing)
 
Member
(Print or type title of person signing)
 
 
Notary Public
 
 
 
Signed and sworn to before me on (date) at Cook County. Illinois.
 
 
»
OFFICIAL SFAt
Commission expires1
 
HEATHER HASENMILLER Notary Public - State of Illinois My Commission Expires Nov 13, 2015
      mm . fefgW
 
 
A Hi
 
 
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
 
 
 
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
 
 
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
 
Under Municipal Code Section 2-154-015. the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related, by blood or adoption, to the mayor, any alderman, the city clerk, the city treasurer, or any city department head as 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 Part" means (1) all corporate officers of the Disclosing Party, 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 member 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 I -GENERAL INFORMATION
  1. Legal name of Disclosing Party submitting this FDS. Include d/b/a/ if applicable: Semir D. Sirazi Irrevocable Trust
Check ONE of the following three boxes:
Indicate whether Disclosing Party submitting this EDS is:
  1. [X] the Applicant
OR
  1. [ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which Disclosing Parly holds an interest:      
OR
    1. [ ] a specified legal entity with a right of control (see Section II.B. I .b) Stale the legal name of the
  2. entity in which Disclosing Party holds a right of control:      
B.      Business address of Disclosing Parly:       500 Elmwood Avenue      
Wilmette. 11 60091      
  1. Telephone:      847-251-8712      Fax:      Email      
  2. Name of contact person: Semir D. Sirazi      
  3. Federal Employer Identification No. (if n oli have one):      
  4. Brief description of contract, transition or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
 
              Zoning Change-2417-33 N Clark Street      
 
 
G. Which City agency or department is requesting this EDS? Dent of Housing & Economic Development
Bureau of Planning & Zoning If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
 
Specification #                  and Contract: #      
 
Vcr. 01-01-12
 
 
 
Page I ol" 13
 
 
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
 
A. NATURF OF DISCLOSING PARTY
 
1. Indicate the nature of the Disclosing Party: [ ] Person
[ ] Publicly registered business corporation f | Privately held business corporation [ ] Sole proprietorship [ ] General partnership* [ ] Limited partnership* [X] Trust
 
[ j Limited liability company*
f ] Limited liability partnership*
f ] Joint venture*
[ ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes      L J No
| ] Other (please specify)
 
 
♦Note B.l.b below
 
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?
 
C ] No
I I Yes
 
| XI N/A
 
B. IF THE DISCLOSING PART Y IS A LEGAL ENTITY:
 
1.     List below the full names and title 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 titleholdcr(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 legai entity listed below must submit an EDS on its own behalf.
 
Name Title
Lilva Sirazi      Trustee      
 
 
 
 
 
 
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,
 
 
Interest ol"a member or manager in a iimited 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
Lilva Sirazi      500 Elm wood Avenue: Wilmette. IL 60091      100%
 
 
 
 
 
 
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
 
Has the Disclosing Paru has a "business relationship." as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
 
1 | Yes      [XJ 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 & OTHER RETAINED PARTIES
 
The Disclosing Part) 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 soiely through the Disclosing Party's regular payroll.
 
"Lobbyist'' means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (I) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist"" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
 
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party, must either ask the City whether disclosure is required or make the disclosure.
 
 
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)      "hourlyrate'* or "t.b.d." is
not an acceptable response.
 
Anderson & Moore-Attomev 1 1 I \V Washington Ste 1 100: Chicago. IL 60602    Estimated to be      
      $5.000.00      
 
 
(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
  1. 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 term of the contract.
 
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      [X] No      [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
 
If "Yes," has the person entered iiuo a court-approved agreement for payment of all support owned and is the person in compliance with that agreement?
 
| | Yes      [ ] No
  1. 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 the 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 indicated 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 live-year compliance timeframes in certification 2 and 3 below.
 
Page 4 of 13
 
 
2. The Disclosing Party and. if the Disclosing Party is a legal entity, ail of those persons or entities identified in Section II.B.l. of this F.DS:
  1. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from an\ transactions by any federal, state or local unit of government;
  2. have not. within a five-year period preceding that 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 charges 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 transaction (federal, state or local) terminated for cause or default: and
  5. have not. v\ iihin a live-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 ain other unit of local government.
3. The certifications in subparts 3. 4 and 5 concern: i the Disclosing Part}':
o any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited lo any persons or legal entities disclosed under Section IV, '"Disclosure oi"Subcontractors and Other Retained Parties"):
  • any "Affiliated Entity" (meaning a person or entity that, direct!} or indirectly: controls the Disclosing Party, is controlled by the Disclosing Parly, or is. with the Disclosing Party, under common control ol" 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 io do business with federal or state or local government, including the City, using substantially ihe same management, ownership, or principals as the ineligible entity) with respect to Contractors, ihe 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 emit} ;
  • any responsible official of ihe Disclosing Party, an} Contractor or any Affiliated Entity or any other official, agent or employee of ihe Disclosing Pari}, 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 {collective!} "Agents").
 
 
Page 5 of 13
 
 
Neither the Disclosing Party, nor any Contractor, nor any A 111 Mated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
 
a.   bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United Staled of America, in that officer's or employee's official capacity;
 
b   agreed or colluded with other bidders, or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
  1. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct: or
  2. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
  1. 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 stale or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United Stated of America that contains the same elements as the offense of bid-rigging or bid-rotating.
  2. 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 Lists, the Unverified List, the Entity List and the Debarred List.
  3. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative I 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 Panv must explain below:
N/A
 
 
 
 
 
 
Page 6 of 13
 
 
lf 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 alter 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 "\Ar or "none").
      ~ 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 non, indicate with a "N/A"' or "none"'). As to any gift listed below, please also list the name of the City recipient.
      " ~N/A „_^^_       
 
 
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
  1. The Disclosing Party certilies that the Disclosing Parly (check one)
[ ] is      |X| is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
  1. 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 of necessary):
 
 
If the letters "NA." the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
 
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
 
Any words or terms that are defined in Chapter 2-156 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?
M Yes [X]No
 
NOTE:  If you checked "Yes" to Item D. I., proceed to Items D.2. and D.3. If you checked "No" to Item D. I., proceed to Part E.
  1. 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 v irtue 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 w ithin the meaning of this Part D.
 
Does the Matter involve a City Property Saie?
 
[]  Yes      | ! No
  1. If you checked "Yes" to Item D. i provide the names and business addresses of the City officials or employees having such interest and identify the nature of 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 . I f 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 Parly 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 provide coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
 
      2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
 
 
 
 
 
 
SECTION VI -- CERTIFICATIONS FOR FEDERALLY-FUNDED MATTERS
 
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally
funded, proceed to Section VII. For purposes of this Section VI, tax credits allowed 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 as necessary):
 
 
 
 
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the work "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
 
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity io 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 and federally funded contract, grant, loan, or cooperative agreement.
 
  1. The Disclosing Party will 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 information set forth in paragraphs A.l. and A.2. above.
  2. 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) il is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and w ill not engage in "Lobbying Activities".
  3. 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?
I I Yes      [] No
If "Yes." answer the ihree questions below:
  1. 1 lave you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 4! CFR Part 60-2).
I 1 Yes      I ] No
  1. 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 films requirements?
[j  Yes      |f No
  1. Have you pariicipated 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 I Oof 13
 
 
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
 
The Disclosing Party understand and agrees that:
  1. 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.
  2. 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.
  1. 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 ihe 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.
  2. 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 verily the accuracy of any information submitted in this EDS.
  3. 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 lime the City takes action on the Matter, lf 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: Willi respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT iNTELIG 5 BILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
 
The Disclosing Party represents and warrants that:
 
F. 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, i his 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 on the U. S. E.P.A. on the federal Excluded Parties List System ("EPFS) 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 ihe Matter certifications equal in form and substance to those in F. i. 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:  lf 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 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 oiThe date furnished to the Cily.
 
 
Semir D. Sirazi irrevocable Trust      
(Print or type name of Disclosing Party)
 
By:
 
 
 
(Sign here)
 
 
Lilva Sirazi
(Print or type name of person signing)
      Trustee
(Print or type title of person signing)
 
N'otary Public ^ ~ " ~ -
 
% dh m> m
e) ihh
 
 
 
Signed and sworn to before me on (dat< at Cook Countv. Illinois.
 
Commission expires:
OFFICIAL SEAL IrtATflW'TOSETlMTLLER Notary Public - State of Illinois i    My Commission Expires Nov 13, 2015
 
 
':,! I,
 
 
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
 
 
 
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
 
 
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
 
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any '"Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A •'familial relationship" exists if. as of the date this EDS is signed, the Disclosing Party or any "Applicable Party"" or any Spouse or Domestic Partner thereof is related, by blood or adoption, to the mayor, any alderman, the city clerk, the city treasurer, or any city department head as parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, falher-in-iaw, 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 Part" means (i) all corporate officers of the Disclosing Party, if the Disclosing Party is a corporation; all partners of the Disclosing party, if the Disclosing Party is a genera! partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and member 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?
 
[ I Yes      [ X] No
 
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
A. Legal name of Disclosing Party submitting this EDS. include d iva/ if applicable: Semir D. Sirazi Revocable Trust
Check ONE of the following three boxes:
 
Indicate whether Disclosing Part) submitting this EDS is:
  1. [XJ the Applicant
OR
  1. [ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which Disclosing Parly hoids an interest:      
OR
  1. | J a specified legal entity with a right of control (see Section I LB. I .b) State the legal name of the
entity in which Disclosing Parly holds a right of control:      
 
B. Business address of Disclosing Parly:       500 Elmwood Avenue      
Wilmette. IL 60091      
  1. Telephone:      847-251--8712      Fax:      Email      
  2. Name of contact person: Semir D. Sirazi      
  3. Federal Employer Identification No. (if you have one):      
  4. Brief description of contract, transition or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
 
                  Zoning Changc-2417-33 N Clark Street      
 
 
G. Which City agency or department is requesting this EDS? Dept of Housing & Economic Development
Bureau of Planning & Zoning If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
 
Specification *      and Contract #      
 
Vcr. 01 -(11 -12
 
 
 
Page 1 of 13
 
 
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
 
A. NATURE OF 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* [X] Trust
 
[ ] Limited liability company*
[ ] Limited liability partnership*
[ ] Joint venture*
| ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
| 1 Yes      [ ] No
[ ] Other (please specify)
 
 
*Note B. 1 .b below
 
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?
 
[jYes
! j No
 
[Xj N/A
 
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
 
1.     List below the full names and title 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 beiow must submit an EDS on its own behalf.
 
Name Title
Semir D. Sirazi      Trustee      
 
 
 
 
 
 
2.  Please prov ide 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
Semir D. Sirazi      500 I-linwood Avenue: Wilmette. IL 600c)l      100%
 
 
 
 
 
 
SECTION ill - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
 
Has the Disclosing Party has 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 [X]No
 
If yes, please identify bciow the name(s) of such City elected official(s) and describe such relationship(s):
 
 
 
 
SECTION IV - DISCLOSURE OF SUBCONTRACTORS & 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.
 
 
 
 
 
 
 
 
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)      lobby ist, etc)      "hourlyrate"' or "t.b.d." is
not an acceptable response.
 
Anderson & Moore-Attorney 1 I I W Washington Ste 1100: Chicago. IL 60602    Estimated to be      
      S5.000.00      
 
 
 
(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
  1. 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 term of the contract.
 
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?
 
[ J Yes      [X | 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 owned and is the person in compliance with that agreement?
 
I I Yes      | ] No
  1. FURTHER CERTIFICATIONS
 
1.  Pursuant to Municipal Code Chapter 1 -23. Article i ("Article I*")(vvhich the Applicant should consult for defined terms (e.g "doing business"") and legal requirements), if the Disclosing Party submitting the 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 indicated or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certification 2 and 3 below.
 
Page 4 of 13
 
 
2. The Disclosing Parly and. if'the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
  1. arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
  2. have not, within a live-year period preceding that 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 charges 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 transaction (federal, stare 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:
 
o the Disclosing Party;
o any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to any 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;
o 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:
 
a.   bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United Stated of America, in that officer's or employee's official capacity:
 
b    agreed or colluded with oilier bidders, or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guiity of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
  1. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct: or
  2. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
  1. 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 (!) 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 Stated of America that contains the same elements as the offense of bid-rigging or bid-rotating.
  2. 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 Lis:, the Denied Persons Lists, the Unverified List, the Entity List and the Debarred List.
  3. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General). 2-56 (inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
 
7.      If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A       
 
 
 
 
 
 
Page 6 of 13
 
 
If the letters "NA," the- word "None." or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
 
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS. an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A"" or "none").
      " N/A             
 
 
 
9. To the best of the Disclosing Part) "s know ledge 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 lime during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the Cily of Chicago. I or 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 retail value of less than $20 per recipient (if non, indicate
with a "N/A" or "none"'). As to any gift listed below, please also list the name of the City recipient.
       " "n/a
 
 
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
  1. The Disclosing Parly certifies that the Disclosing Party (check one)
| | is      IX] is not
a "financial institution"' as defined in Section 2-32-455(b) of the Municipal Code.
  1. 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 Cily."
 
If the Disclosing Parly is unable io make this pledge because it or any of its affiliates (as defined in Section 2-32-45 5(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages of 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.
  1. In accordance with Section 2-156-1 10 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
I I Yes [XjNo
NOTE:  If you checked "Yes" to Item D. I proceed to Items D.2. and D.3. If you checked "No" to Item D. I proceed to Part E.
  1. 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 oflegal 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 I Yes      [ J No
  1. If you checked "Yes" to Item D. 1 provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
 
Name      Business Address      Nature of Interest
 
 
 
 
 
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
 
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
 
Please check either I. or 2. beiow . 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_ I. 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 provide 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: Ef 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 allowed 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 19°5 who have made lobbying contacts on behaif of the Disclosing Party with respect to the Matter: (Add sheets as necessary):
 
 
 
 
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the work "None" appear, it w ill 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 lo the Matter.)
 
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law. a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or io extend, continue, renew, amend, or modify and federally funded contract, grant, loan, or cooperative agreement.
 
 
Page 9 of 13
 
  1. 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.
  2. 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".
  3. 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?
I JYes      [] No
If "Yes." answer the three questions below:
  1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2).
I I  Yes      | | No
  1. 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 filine requirements?
I I  Yes      | f.SV,
  1. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
| |  Yes     '       | ; No
 
If you cheeked "No" to question I. or 2. above, please prov ide an explanation:
 
 
 
 
 
 
 
Page 10 of 13
 
 
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
 
The Disclosing Parts-' understand and agrees that:
  1. 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 svith all statutes, ordinances, and regulations on which ihis EDS is based.
  2. 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 mas- also be obtained from the City's Board of Ethics, 740 N.
 
Sedgsvick St., Suite 500, Chicago. II. 60610. (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
  1. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with svhich 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 lass, 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.
  2. 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 io ihe 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 svith 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.
  3. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT INTE'LIG IBILITY 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 Parts represents and warrants that:
 
 
 
 
Page 11 of 13
 
 
F. I.    The Disclosing Parry 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.    lf the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use. nor permit their subcontractors to use. any facility on the U. S. E.P.A. on the federal Excluded Parties List System ("FPUS) maintained by the U.S. General Services Administration.
 
F.3.    lf the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Manor certifications equal in form and substance to those in F. I. 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.
 
 
CERTIFICATION1
 
Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furn ished to the City.
 
 
Semir D. Sirazi ffc&locabie Trust      
(Print or type name of Disclosing Party)
 
(Sign here)
 
Semir D. Sirazi      
(Print or type name of person signing)
 
Trustee      
(Print or type title of person signing)
 
 
 
 
 
 
 
 
 
 
      ■ ■ ■ i
~      Page 12 of 13
 
 
 
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
 
 
 
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
 
 
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
 
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if. as of the date this FDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof Is related, by blood or adoption, to the mayor, any alderman, the city clerk, the city treasurer, or any city department head as 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 Pari" means (I) all corporate officers of the Disclosing Party, 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 Parly, if the Disclosing Parly is a limited partnership: all managers, managing members and member 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      L X.| No
 
If yes. please identify beiovv (!) 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 lias a familial relationship, and (4) the precise nature of such familial relationship.
 
 
 
 
 
 
 
 
 
 
Pase 13 of 13
 
 
 
 
ALTA/ACSM LAND TITLE SURVEY
 
 
 
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1
 
 
 
 
 
 
ALTA/ACSM LAND TITLE SURVEY
 
Legal Description: COMMERCIAL PROPERTY "A"
The property and space ot the first floor of a 2 story and basement building at 2417-2433 North Clark Street, Chicago, Illinois, hying between horizontal plones ot elevations of 21.50 feet and 32.76 feet, City of Chicago Datum and lying within the following described boundaries of the port of the Southerly 102 feet and 1/2 inch of the Westerly 215 feet of Lot 4 in Doird's Lincoln Park Addition to Chicogo. being o Subdivision in the Southeast Quarter of Section 28, Township 40 North. Range 14, East of the Third Principal Meridian, in Cook County, Illinois, described as follows:
Commencing at a point on the Easterly line of North Clark Street and the Westerly line of soid Lot 4, 1.28 feet Southerly of the Northerly line of the Southerly 102 feet and 1/2 inch of said Lot 4; thence Southerly on the Westerly line of soid Lot 4, 15.78 feet; thence Easterly at right angles, 17.61 feet; thence Northerly at right angles, 1.50 feet; thence Easterly at right angles, 1.40 feet; thence Southedy ot right angles, 1.25 feet; thence Easterly ot right angles. 10.65 feet; thence Northerly ot right angles, 4.64 feet; thence Easterly at right ongles, 6.76 feet; thence Southerly at right angles, 3.30 feet; thence Eosterly at right angles, 0.64 feet; thence Southerly at right ongles. 0.83 feet; thence Easterly, 19.20 feet to o point 56.18 feet Eosterly of the Westerly line of said Lot 4 and 14.41 feet Southerly of the Northerly line of the Southerly 102 feet and 1/2 inch of said Lot 4; thence Northerly parallel to the Westerly line of said Lot 4, 1.84 feet; thence Eosterly at right ongles. 1.06 feet; thence Southerly ot right angles, 1.B4 feet; thence Easterly ot right angles, 11.44 feet; thence Northerly ot right angles, 13.11 feet to o point 1.30 feet Southerly of the Northerly line of the oforesoid Southerly 102 feet and 1/2 inch of Lot 4; thence Westerly 68.68 feet to the ploce of beginning, in Cook County, Illinois.
COMMERCIAL PROPERTY "B"
The property and spoce at the first floor of a 2 story and basement building at 2417-2433 North Clark Street. Chicago, Illinois, lying between horizontal plones ot elevations of 21.50 feet and 32.83 feet. City of Chicago Datum and lying within the following described boundaries or the part of the Southerly 102 feet and 1/2 inch of the Westerly 215 feet of Lot 4 in Baird's Lincoln Park Addition to Chicago, being o Subdivision in the Southeast Quarter of Section 28, Township 40 North, Range 14, East of the Third Principal Meridian, in Cook County, Illinois, described as follows:
Commencing at a point on the East line of North Clark Street and the West line of Lot 4. 37.15 feet Southerly of the Northerly line of the aforesaid Southerly 102 and 1/2 inch of soid Lot 4; thence Easterly at right angles to said Lot line, 1.95 feet; thence Northerly ot right angles, 2.57 feet; thence Eosterly at right angles, 15.66 feet; thence Southerly ot right ongles, 1.72 feet; thence Easterly at right angles, 1.75 feet; thence Northerly ot right angles. 1.72 feet; thence Easterly at right angles, 16.33 feet; thence Southerly ot right angles, 1.55 feet; thence Eosterlt 1.72 feet; thence Northerly at right ongles, 1.55 feet; thence Eosterly 5.96 feet to a point 43.23 feet Easterly of the Westerly line of said Lot 4 and 35.86 feet Southerly of the Northerly line of the Southerly 102 feet 1/2 inch of said Lot 4; thence Easterly, 5.62 feet to a point 47.13 feet Easterly of the Westerly line of soid Lot 4 and 39.90 feet South of the Northerly line of the Southerly 102 feet 1/2 inch of said Lot 4; thence Easterly porollel to the Northerly line of soid Southerly 102 feet 1/2 Inch of said Lot 4. 5.80 feet; thence Northerly ot right ongles, 2.98 feet; thence Easterly 3.17 feet to a point 56.06 feet Easterly of the Westerly line of said Lot 4 and 37.42 feet Southerly of the Northerly line of soid Southerly 102 feet 1/2 inch of said Lot 4; thence Southerly porollel to the Westerly line of soid Lot 4, 1.75 feet; thence Easterly at right ongles, 1.75 feet; thence Northerly at right ongles. 1.75 feet; thence Easterly at right angles, 19.57 feet; Ihence Southerly ot right ongles, 2.11 feet; thence Easterly at right angles, 1.26 feet; thence Northerly at right angles, 2.11 feet; thence Eosterly ot right angles, 20.02 feet; thence Southerly at right angles. 1.17 feet; thence Eosterly at right angles, 1.24 feet to o point 99.90 feet Easterly of the Westerly line of said Lot 4; thence Southerly parallel to the Westerly line of said Lot 4, 23.85 feet; thence Westerly ot right angles, 1.20 feet; thence Southerly at right ongles, 2.15 feet; thence Eosterly ot right ongles, 1.20 feet; thence Southerly at right angles, 22.93 feet; thence Westerly at right angles. 1.06 feet; thence Southerly ot right angles. 1.62 feet; thence Easterly at right cngles, 1.06 feet; thence Southerly at right angles, 5.31 feet; thence Westerly at right angles, 1.20 feet; thence Southerly ot right angles, 6.20 feet to a point 100.87 feet Southerly of the Northerly line of the Southerly 102 feet 1/2 inch of soid Lot 4; thence Westerly 9B.70 feet to a point in the Westerly line of soid Lot 4. 100.82 feet Southerly of the Northerly line of the Southerly 102 feet 1/2 inch of soid Lot 4; thence Northerly on the Westerly line of said Lot 4, 63.67 feet to the ploce of beginning, in Cook County, Illinois.
COMMERCIAL PROPERTY X"
The property and space at the first Moor of a 2 story building at 2417-2433 North Clark Street, Chicago, Illinois, lying between horizontal planes at elevations of 22.00 feet and 35.87 feet, City of Chicago Datum and lying within the following described boundaries of that port of Lot 2 in R. Lotholz's Subdivision of Lots 6 and 7 in Baird's Lincoln Park Addition to Chicago, being a Subdivision of the Southeast corner of the Southwest Quarter of Section 28. Township 40 North, Range 14, East of the Third Principal Meridian, according to the plat thereof recorded Morch 11, 1907 os Document No. 4001675. in Book 95, Page 17, in Cook County, Illinois, described as follows:
Ccmmencing ot a point on the East line of North Clark Street and the West line of said Lot 2, 100.08 feet Northerly of the Southwest comer of said Lot 2; thence Southerly on the Westerly line of said Lot 2, 99.02 feet; thence Easterly on o line 1.06 feet Northerly of and parallel to the Southerly line of soid Lot 2. 88.82 feet; thence Northerly ot right ongles, 2.45 feet; thence Eosterly ot right angles, 39.16 feet; thence Northerly ot right ongles, 7.53 feet; thence Eosterly ot right ongles. 28.05 feet; thence Northerly at right angles, 18.15 feet; thence Easterly at right angles, 7.04 feet; thence Northerly ot right angles, 7.37 feet; thence Westerly ot right angles, 7.04 feet; thence Northerly at right angles, 15.9B feet to a point 52.54 feet North of the South line of said Lot 2; thence Westerly parallel to the South line of said Lot 2, 6.07 feet; thence Westerly on o curve convex to the South, Radius of 1.0 feet, 1.45 feet to o point on soid line 52.54 feet North of the South line of said Lot 2; thence Westerly on said parallel line, 18.33 feet; thence Westerly on o curve convex to the South, Radius of 1.0 feet, 1.45 feet to a point on said parallel line; thence Westerly on soid parallel line, 19.63 feet; thence Eosterly on o curve convex to the South, Radius of 1.0 feet, 1.45 feet to a point on said porollel line; thence Westerly on soid parallel line, 0.10 feet; thence Northerly ot right angles, 3.96 feet; thence Westerly at right ongles. 13.01 feet; thence Northerly at right angles. 4.80 feet; thence Eastedy ot right angles, 5.03 feet; thence Northerly ot right ongles, 37.50 feet to a point 99.92 feet East of the West line and 99.80 feet North of the South line of said Lot 2; thence Westerly on o line parallel to the North line of soid Lot 2, 7.20 feet; thence Northerly at right angles, 0.40 feet; thence Westerly at right angles, 5.65 feet; thence Northerly ot right angles, 1.16 feet; thence Westerly ot right angles, 18.10 feet; thence Southerly ot right angles, 1.16 feet; thence Westerly ot right ongles, 4.08 feet; thence Northerly at right angles. 0.BB feet; thence Westerly porollel to the Northerly line of soid Lot 2. 15.45 feet; thence Southerly ot right angles, 0.B8 feet; thence Westerly at right angles. 4.85 feet; thence Northerly ot right angles, 0.88 feet; thence Westerly parallel to the Northerly line of soid Lot 2, 17.34 feet; thence Southerly at right angles, 1.54 feet; thence Westerly at right angles, 4.65 feet; thence Northerly at right angles, 1.54 feet; Ihence Westerly, 22.50 feet to the place of beginning, all in Cook County, Illinois.
commonly known os: 2417-33 North Clark Street; Chicago, Illinois.
 
PAGE 2 OF 3
 
 
LP.LAL A.C&L
M4 CUSTI* AVENUE, EVAflSTON, ILLINOIS WW TEL. (147) W43 Ii / FAX (147) IW-Uil E-ftUIb SUim'OBtimUlDLCUM
 
,2*17-33 H. CLARK ST.
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12-119
J9            »nM, - ■ *Y ZABEL k ASSOCIATES. LTD.
 
 
 
 
 
 
ALTA/ACSM LAND TITLE SURVEY
PARCEL 1:
Lot 2 in R. Lotholz*! Subdivision ol Lots 6 and 7 in Sard's Lincoln Pork Addition to Chicago, being o Subdivision of the Southeast quarter ol the Southwest quarter of Section 28, Township 40 North, Range 14, East ol the Third Principal Meridian, according to the plat thereof recorded March 11, 1907, as Document Ho. 4001675, in Book 95, Page 17, in Cook County, Illinois.
PARCEL 2:
The Southerly 102 It. 1/2 inch of the Westerly 215 It. or Lot 4 in Boird'i Lincoln Park Addition to Chicago, being o Subdivision in the Southeast corner of the Southwest quarter of Section 2B, Township 40 North, Range 14. Eost ol the Third Principal Meridian, in Cook County. Illinois.
 
commonly known as: 2417-23,24251/2-33 N. Clark Street, Chicago, Illinois.
COCKTI Wii. 1IT IH1
 
the East ine ol Ctafh Street being
This peat prepared Tor information ort> in pogt 2 lor property deicriptoi. tee peat 1 lot parcels.
~-M»W U* OF RESTFUUnrOKHKWAT
 
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flood Zone Designation:
Per Flood (niuranct Rati Map No.17Q31C0417J. EUectne date Aucust 1" """" Thi Surveyed Property ii located in Zone V. Area determined to be ouiiide of the 0.21 annual chance Ibodplain.
Rtlertfice:
 
For matlcn of I UK *t hove relied on Title Insurance Company's Commitment lor Title injur once. Order No. 1412 W5AUC09Q LP1 02, Effeclrv* Date January IS, 2012, for all recorded document! a flic ting the descrbed pared).
 
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PAGE 1 OF 3
R.R. HANSEN
MUBEt:
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B.H. SUIE^&~€()MPANY, ING7
■uzrrrau bjtuusid mi lit CUSTEl AVtffUt, EVAnSTON, ILLINOIS (UD TU-(W7)I« UU / FAX(141)W4-K4I
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2417-33 N. CLARK ST.
 
1 limited fcbiEty company and
Certify To: CMS Ctork LLC. a Chicago Tills and Trust Company:
This is to certify that this mop or plot and the survey on which it is based «re made
accordance with the 2011 Ur.Imum Standard Detail Requirements (or ALTA/ACSM Land Title Surveys, jointly established and adopted by ALTA and USPS, ond includes items 1. 2, 3. 4, 7(a). 8. Ufa), and 14 of Table A thereof. The (kid work was completed on Apia 23. 2011
Dcttd ot Evomlon, ■„ this      day of      AD., 20      
 
JAY ZABEL k ASSOCIATES, LTD