Office of the City Clerk - Record #: O2013-6091

This record contains private information, which has been redacted from public viewing.

Record #:

O2013-6091

Type:

Ordinance

Status:

Passed

Intro date:

9/11/2013

Current Controlling Legislative Body:

Committee on Zoning, Landmarks and Building Standards

Final action:

10/16/2013

Title:

Zoning Reclassification Map No. 3-H at 1601-1615 W Division St and 1148-1156 N Ashland Ave - App No. 17819

Sponsors:

Misc. Transmittal

Topic:

ZONING RECLASSIFICATIONS - Map No. 3-H

Attachments:

1. O2013-6091.pdf

Date	Journal Page Number	Action By	Action	Result	Action Details	Meeting Details	Captions
10/16/2013	62759	City Council	Passed	Pass	Action details	Meeting details	Not available
10/10/2013		Committee on Zoning, Landmarks and Building Standards	Recommended to Pass	Pass	Action details	Meeting details	Not available
9/11/2013	58799	City Council	Referred		Action details	Meeting details	Not available

ORDINANCE

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

SECTION 1. That the Chicago Zoning Ordinance be amended by changing all the current RM6.5 Residential Multi-Unit District symbols and indications as shown on Map No. 3-H in the area bounded by:

West Division Street; North Ashland Avenue; a line 122.25 feet south of West Division Street; and a line 149.04 feet west of North Ashland Avenue

to those of a B3-5 Community Shopping District which is hereby established in the area described above.

SECTION 2. This Ordinance shall be in force and effect from and after its passage and due publication.

CITY OF CHICAGO _ py. j ^ ^ _Q ,3

APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE

ADDRESS of the property Applicant is seeking to rezone:

1601 - 15 West Division Street/1148-56 North Ashland Avenue

Ward Number that property is located in: 1
APPLICANT 1601 West Division LLC '

ADDRESS 1910 West Division Street

CITY Chicago STATE IL ZIP CODE 60622

PHONE 312-636-6937 CONTACT PERSON Rolando R Acosta

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

If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:

ATTORNEY Rolando Acosta

ADDRESS 2949 W. Gregory St. CITY Chicago

CITY Chicago STATE IL ZIP CODE 60625

PHONE 312-636-6937 FAX 312-253-4440

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.

1601 West Division Founders LLC; 2300 Partners, LLC; Wendy M. Serrino

On what date did the owner acquire legal title to the subject property? 2011
Has the present owner previously rezoned this property? If Yes, when?
Yes, June, 2012
Present Zoning District RM6.5 Proposed Zoning District B3-5

10. Lot Size in square feet (or dimensions) 16,678 sf

11. Current Use of the property 12 story mixed-use building with 99 residential

units, ground floor retail, including a bank drive-thru, second floor retail/office uses, 15 shared

parking spaces and 1 loading berth.

Reason for rezoning the property: Expand the available signage for retail/commercial

tenants

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 o the proposed building. (BE SPECIFIC) Existing 12 story

mixed-use building with 99 residential units, ground floor retail, including a bank drive-thru,

second floor retail/office uses, 15 shared parking spaces and 1 loading berth to remain with

the addition of adequate on-premises signage.

14. On May 14^th, 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

I, £>uofto , being first duly sworn on oath, statesthat all of the above

statements and the statements contained in the documents submitted herewith are true and correct.

Subscribed and Sworn to me before this

Signature of Applicant

Robert Buono! M anager of M anager,

1601 West Division Manager LLC

1 Notary RibHc, 8urt* at Mnote

Notary Public £ MyComn^E^awaoie

For Office Use Only

Date of Introduction: File Number: Ward:

- JA38 JAIOIW

September 2, 2013

Chairman, Committee on Zoning Room 304, City Hall Chicago, Illinois 60602

Chairman:

The undersigned, Rolando R. Acosta, being first duly swom on oath, deposes and say the following:

That the undersigned certifies that he has complied with the requirements of the Chicago Zoning Ordinance, Title 17, Section 13-0107-A of the Municipal Code of Chicago, by serving written notice by USPS first class mail, to the owners of all property within 250 feet in each direction of the lot lines of the subject property, the boundaries of which are:

West Division Street; North Ashland Avenue; a line 122.25 feet south of West Division Street; and a line 149.04 feet west of North Ashland Avenue

exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet, and that the notice contained the address and description of the property which is the subject of the application under the Chicago Zoning Ordinance; a statement of the intended use of said property; the name and address of the applicant; and a statement that the applicant intends to file said application on approximately September 2, 2013; that the applicant has made a bona fide effort to determine the addresses of the parties to be notified under the cited section of the Municipal Code of the City of Chicago; that the applicant certifies that the accompanying list of names and addresses of surrounding property owners within 250 feet, recognizing the above limits, is a complete list containing the names and last know addresses of the owners of the property required to be served and that the applicant has fumish^djri^djtion a list of the persons so served.

By:

Subscribed and sworn to before me this September 2, 2013.

Notary Public

"OFFICIAL SEAL" MABEL V. ORAMA Notary Public, State of Illinois My Commission Expires 08/06/14

September 2, 2013

Dear Sir or Madam:

Please take notice that under the Chicago Zoning Ordinance an application (the "Application") to change the RM6.5 Residential Multi-Unit District classification to those of a B3-5 Community Shopping District for the area which is bounded by:

West Division Street; North Ashland Avenue; a line 122.25 feet south of West Division Street; and a line 149.04 feet west of North Ashland Avenue

(hereafter the "Property") will be filed on or about September 2, 2013 with the Department of Housing and Economic Development, City of Chicago by 1601 West Division LLC, 1910 W. Division St., Chicago, IL 60622 (hereinafter the "Applicant"). The addresses of the Property are 1601 - 15 West Division Street/1148 - 56 North Ashland Avenue, Chicago, IL. The Applicant is the owner of the Property.

The Property currently is improved with a twelve story building containing 99 residential units, ground floor retail space, including a bank drive-thru, second floor retail/office space, 15 shared parking spaces and one loading berth. The Application, if approved, will allow the Applicant to provide adequate signage for the retail and office tenants.

This notice is required by the Chicago Zoning Ordinance, Title 17, Section 17-13-0107-A of the Municipal Code of Chicago. It is being sent to you because you appear as a taxpayer of record within 250 feet of the Property. The Application will not rezone your property. Any questions regarding this notice may be direct to the undersigned at 312-636-6937.

Sincerely

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 1601 West Division LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[x] the Applicant

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

Applicant in which the Disclosing Party holds an interest:

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

which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 1910 West Division St.

Chicago, IL 60622

Telephone: 312-636-6937 p_ax: 312-253-4440 Email: rolando@acostalawpc.com
Name of contact person: Rolando R. Acosta
Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

Rezoning of 1601 - 15 West Division Street/1148 - 56 North Ashland Avenue

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

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. MATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party: ] Person f>

J Publicly registered business corporation [

J Privately held business corporation [

] Sole proprietorship [

J General partnership (

J Limited partnership

|X] Limited liability company [ ] Limited liability partnership [] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

] Trust [

[ ] Yes [ ] No

[ j Other (please specify)

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

Illinois

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

[JYes

UNo

(XI N/A

U. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title

1601 West Division Manager LLC Manager

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

1601 West Division Founder LLC 1910 W. Division St., Chicago, IL 60622 25.36%

2300 Partners, LLC 2300 S. Archer Ave., Chicago, IL 60616 14.49%

Wendy M. Serrino 130 Beach Rd., Glencoe, fL 60022 8.70%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ J Yes [xj No

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

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the M atter, 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) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

Rolando R. Acosta 2949 W. Gregory St., Chicago, IL 60625 Atty $5,000 (est)

(Add sheets if necessary)

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

COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

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

Disclosing Party.

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

L J Yes L j No

FURTHER CERTIFICATIONS

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

Page 4 of 13

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

arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against 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;
arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and

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.

The certifications in subparts 3, 4 and 5 concern:

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

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

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

Page 6 of 13

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

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

None

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

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [Xj is not

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

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

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

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

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[ J Yes W No

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

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

Docs the Matter involve a City Property Sale?

L J Yes [ ] No

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. 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 provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

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

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

Page 9 of 13

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

B. CER TIFICATION 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 L J No

If "Yes," answer the three questions below:

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

[ ] Yes L J No

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

[ ] Yes L J No

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

[ ] Yes [ ] No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

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

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

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page II of 13

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

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

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

1601 West Division LLC

(Print or type name of Disclosing Party)

J (Sign here/ Robert Buono

(Print or type name of person signing)

Manager of Manager, 1601 West Division Manager LLC (Print or type title of person signing)

at Cook

(state).

Signed and swom to before me on (date) n II5H3

County,: '"inois

Commission expires:_

Page 12 of 13

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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A

FAMILIAL RELATIONSinPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

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

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 1601 West Division Manager LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

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

Applicant in which the Disclosing Party holds an interest:

3. |X] a legal entity with a right of control (see Section II. 13.1.) State the legal name of the entity in

which the Disclosing Party holds a right of control: 1601 West Division LLC

Business address of the Disclosing Party: 1910 W. Division St.

Chicago, IL 60622

Telephone: 312-636-6937 p_ax: 312-253-4440 Email: rolando@acostalawpc.com
Name of contact person: Rolando R. Acosta
Federal Employer Identification No. (if you have one):

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

Rezoning of Lhe property at 1601-15 West Division Street/1148 - 56 North Ashland Avenue

Which City agency or department is requesting this EDS? DHED

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 1 of 13

SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party: U Person p

[ J Publicly registered business corporation [

[ ] Privately held business corporation [

[ ] Sole proprietorship [

[ J General partnership (

Limited liability company [ j Limited liability partnership [ ] Joint venture [ j Not-for-profit corporation

L J Yes [JNo [ ] Other (please specify)

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

[ ] Limited partnership

[ ] Trust [

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?

[JNo

IJ Yes

M N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

Name Title

Robert Buono Manager Paul Utigard Manager Mark Fisliman Manager

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary ofa trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the M unicipal 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

Robert Buono 1910 W. Division St., Chicago, IL 60622 33.33% Paul Utigard 33.33%

Mark Fishman 3215 West Fullerton, Chicago, IL 60647 33.33%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ j Yes Lxl No

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

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

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

Page 3 of 13

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

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

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

not an acceptable response.

(Add sheets if necessary)

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

COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

Disclosing Party.

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

[ j Yes L J No

FURTHER CERTIFICATIONS

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

Page 4 of 13

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

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

the Disclosing Party;

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

Page 5 of 13

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

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

Page 6 of 13

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

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [X] is not

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

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

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

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

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[ J Yes be] No

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

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

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

Page 9 of 13

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

L J Yes [ ] No

If "Yes," answer the three questions below:

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

L ] Yes [ ] No

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

[ ] Yes [ ] No

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

[ J Yes [ ] No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

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

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

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the M unicipal 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 listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements; contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

1601 West Division Manager LLC

(Print or type name of Disclosing Party)

fsign here) '

Robert Buono .

(Print or type name of person signing)

Manager

(Print or type title of person signing)

Signed and swom to before me on (date)

at Cook County,: '"inois (state).

Page 12 of 13

Commission expires:_

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CITY OK CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 1601 West Division Founder LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

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

Applicant in which the Disclosing Party holds an interest: 1601 West Division LLC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: 1910 W. Division St.

Chicago, IL 60622

Telephone: 312-636-6937 Fax: 312-253-4440 Email: rolando@acostalawpc.com
Name of contact person: Rolando R. Acosta
Federal Employer Identification No. (if you have one):

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

Rezoning of the property at 1601 - 15 West Division Street/1148 - 56 North Ashland Avenue

Which City agency or department is requesting this EDS? DHED

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

Specification # and Contract #

A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of the Disclosing Party:

Person [XJ Limited liability company

Publicly registered business corporation [ ] Limited liability partnership

Privately held business corporation [ ] Joint venture

Sole proprietorship [ ] Not-for-profit corporation

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

Limited partnership [ ] Yes [ ] No

Trust [ ] Other (please specify)

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

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

[ J Yes [ ] No [Xj N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

Name Title

Norwol Corporation Manager

Porro Inf 11

interest oi a memoer or manager in a limited naonny company, or interest or a oenenciary oi 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

Newgard Development LLC 33.00%

2004 Robert Buono Irrevocable Trust 16.50%

2004 Elizabeth Cicchclli Irrevocable Trust 16.50%

Westgate Acquisitions LLC 3215 W. Fullerton, Chicaog, IL 60647 33.00%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ ] Yes W No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The 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: (! ) 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.

Porto 1 r^f 11

iName (indicate wnetner Business retained or anticipated Address to be retained)

Keiationsnip to Disclosing f arty (subcontractor, attorney, lobbyist, etc.)

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

(Add sheets if necessary)

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

COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

Disclosing Party.

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

[ ] Yes [ ] No

FURTHER CERTIFICATIONS

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

Pinp A (i"T 1 1

z. i ne Disclosing rarty ana, n tne Disclosing farty is a legal entity, an ot tnose persons or entities identified in Section II.B.l. of this EDS:

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

3. The certifications in subparts 3, 4 and 5 concern:

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

Porto ^ r.f 11

iNeitner tne Disclosing f any, nor any contractor, nor any Aiiinatea tintity ot eitner tne Disclosing rarty or any Contractor nor any Agents have, during the five years before the date this CDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

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

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

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.

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [Xj is not

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

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

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

Porto 7 r,f 11

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[]Yes IxJNo

NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D. 1., proceed to Part E.

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

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Porto 8nf H

comply wnn mese aisciosure requirements may make any contract enterea into witn tne uity 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 provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

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 ofa member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Porro Q_nf n

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

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

[ ] Yes [ ] No

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

[ ] Yes [ J No

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

[ ] Yes [ ] No

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

Porto IHnf 11

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

The Disclosing Party understands and agrees that:

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

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

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 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:

Porrc 11 nf n

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

F.3 If the Disclosing Party is the Applicant, the Disclosing Party wiD obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractoi/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

1601 West Division Founder LLC (Print or type name ofj^isclosmg Party)

By: 'rZ[^

(S'ignhere)' ^ T

Robert Buono

(Print or type name of person signing)

President of Manager, Nonvol: Corporation (Print or type title of person signing)

Signed and sworn to before me on (date) ~7 I <Sj 13

at Cook County,; Illinois (state).

7^7- Notary Public.

Commission expires:_

Page 12 of 13

"OFFICIAL SEAL" I My Cumwimgn BHwawOOW

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

[ J Yes [X] No

Pono 17 r.f 17

CITY OF CHICAGO ECONOMIC DISCLOSURE S1A1EMENI AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 2004 Robert Buono Irrevocable Trust

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1 f] the Applicant OR

2 |XJ a legal entity holding a direct oi indirect intciest in the Applicant. State the legal name of the

Applicant in which the Disclosing Patty holds an interest: 1601 West Division LLC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: 1610 W. Division Si.

Chicago, IL 60622

C. Telephone: 312-636-6937 _taK. 312-253-4440 Email: rolando@acostalawpc.COm

D Name of contact peison: Rolando Ft. Acosta

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

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

Rezoning of the property at 1601 - 15 West Division Street/1148 - 56 North Ashland Avenue

G Which City agency or department is requesting this EDS? VrLbU

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

Specification it and Contiact #

Vcr 01-01-12

Page 1 of 13

SECTION II DISCLOSURE OF OWNERSHIP INTERESTS

A NATURE OF THE DISCLOSING PARTY

[ ] Limited liability company [ ] Limited liability paitneiship [ ] loint venture [ ] Not-foi-profit coipoiation (Is the not-f'oi-piofit corporation also a 501(c)(3))?

[ ] Limited partnership

I Indicate the natiuc of the Disclosing Patty: [ ] Peison [ [j Publicly registered business corporation [ [] Privately held business coipoiation [ [ ] Sole proprietorship [ [ ] General partnership (I

|XJ Trust [

[ ] Yes f 1 No

[ ] Other (please specify)

2 For legal en tities, the state (oi foreign country) of incorporation oi 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?

[>]N/A

I] No

t ] Yes

B IF IHE DISCLOSING PARTY IS A LEGAL ENTITY:

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

If the entity is a general paitneiship, 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 oi entity that controls the day-to-day management of the Disclosing Patty NOTE: Each legal entity listed below must submit an EDS on its own behalf

Name Title

James J. Gatziolis Trustee

2. Please provide the following information concerning each person oi entity having a direct or indirect beneficial interest (including owneiship) 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 1.3

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

Name Business Address Percentage Interest in the

Disclosing Party

El j aaheth Cicchelli LQOJs.

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-J56 of the Municipal Code, with any City elected 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 rclationship(s):

SECllON IV DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business addr ess 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 Mattel , as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

If the Disclosing Patty 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 Parly Fees (indicate whether

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

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

not an acceptable response.

(Add sheets it necessary)

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

A COURI-ORDERED CHILD SUPPORT COMPLIANCE

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

[ ] Yes [>§ No [ ] No peison directly or indirectly owns 10% or moie of the

Disclosing Party

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

[ ] Yes [ ] No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Patty certifies as follows: (i) neither the Applicant nor any controlling peison is currently indicted or chaiged with, or has admitted guilt ol, or has evei been convicted of. or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, per jury, 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 Aiticlc 1 applies to the Applicant, the permanent compliance timeframe in Aiticle I supersedes some five-year compliance timeframes in certifications 2 and 3 below

Page 4 of 13

2 The Disclosing Patty and. if the Disclosing Party is a legal entity, all of those persons 01 entities identified in Section II B 1. of this EDS:

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

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

c. are not presently indicted for, or criminally oi civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B 2.b. of this Section V;

d have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and

e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, oi found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.

3,. The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;

any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons oi legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a peison or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization ofa business entity following the ineligibility ofa business entity lo 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 Parly, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization ofa responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents")

Page 5 of 13

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

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

Neither the Disclosing Party, Affiliated Entity or Contractor , or any of their employees, off icials, 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'(J) bid-rigging in violation of720 ILCS 5/33E-.3; (2) bid-rotating in violation of 720 ILCS 5/3.3E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable r equirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Jnspcctoi General) and 2-156 (Gover nmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Patty must explain below:

Page 6 of 13

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

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

None

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

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

f J is JX) is not

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

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

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

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

Page 7 of 13

If the letters "NA," the woid "None," or no response appears on the lines above, it will be conclusively ptesurned that the Disclosing Party certif ied to the above statements

D. CERTIFICATION REGARDING TNIEREST IN CITY BUSINESS

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

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

[ ] Yes No

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

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

Does the Matter involve a City Property Sale?

[JYes []No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either J 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 contiact 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

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

SECTION VI -- CERT IFICATIONS FOR FEDERALLY FUNDED MAI IERS

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

A CERTIFICATION REGARDING LOBBYING

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

(If no explanation appeats oi begins on the lines above, or if the letteis "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter )

2 The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person oi entity listed in Paragraph A 1. above for his or her lobbying activities or to pay any peison or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee ofa member of Congress, in connection with the award of any federally funded contiact, making any federally funded giant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contiact, giant, loan, or coopeiative agreement.

Page 9 of 13

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Patty 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

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

[ ] Yes [ ] No

Flave you paiticipated 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 :

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

The Disclosing Party imdeistands and agrees that:

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

C If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the conti act or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Mattel and/or declining to allow the Disclosing Party to participate in other transactions with the City Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages,

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

The Disclosing Party represents and warrants that:

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r.i. The Disclosing Patty is not delinquent in the payment of any tax administexed by the Illinois Department of Revenue, nor are the Disclosing Party ot its Af filiated 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 theii subcontractors to use, any facility listed by the USE P. A. on the federal Excluded Parties List System ("EPLS") maintained by the U.S. General Services Administration.

F .3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided oi cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in f 1., F 2 oi F 3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of pet jury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

2004 Robert Buono Irrevocable Trust

James J. Gatziolis

(Print oi type name of pet son signing)

Trustee

(Print or type title of person signing)

(state).

Signed and swom to before mc on (date)

ut Cook County, Illinois

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 ot Domestic .Partner thereof currently has a "familial relationship" with any elected city official ot department head. A "familial relationship" exists if, as of The date this EDS is signed, the Disclosing Party or any "Applicable Patty" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city cleik, the city heasurei or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, gr andchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or- stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l a , if the Disclosing Party is a corporation; all paitners 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 Paity is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7 5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority

Does the Disclosing Party or any "Applicable Party" or any Spouse or- Domestic Partner thereof cunently have a "familial relationship" with an elected city official ot 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 peison 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 T - GENERAL INFORMATION

A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 2004 Elizabeth Cicchelli Irrevocable Trust

Check ONE of the following three boxes:

Indicate whether the Disclosing Paity submitting this EDS is: 1. [ ] the Applicant OR

2 [)<j a legal entity holding a direct oi indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: 1601 West Division LLC

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

which the Disclosing Party holds a right of control:

B Business address of the Disclosing Party: 1610 W. Division St.

Chicago, IL 60622

C. Telephone: 312-636-6937 p_ax: 312-253-4440 Email: rolandO@acostalawpc.com

D Name of contact person: ^Rolando ^R- ^Acosta

£. federal Employer Identification No (if you have one):

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

Rezoning of the property at 1601 - 15 West Division Street/1148 - 56 North Ashland Avenue

G Which City agency or department is requesting this EDS? DHED

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

Specification # and Contiact #

Vcr. 01-01-12

Page 1 of 13

SECTION II -

- DISCLOSURE OF OWNERSHIP INTERESTS

A NATURE OF THE DISCLOSING PARTY 1 Indicate the natute of the Disclosing Party:

I ] Peison [ J

[ J Publicly registered business coipoiation [ ]

[ ] Privately held business corporation [ ]

[ ] Sole proprietorship [ ]

[ ] General partnership (Is

[ ] Limited partnership

N Trust []

Limited liability company Limited liability paitneiship Joint venture

Not-for-profit coipoiation

the not-foi-piofit coipoiation also a 501(c)(3))?

[ ] Yes [ ] No

Other (please specify)

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

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

[ J Yes [ ] No jq N/A

F3 IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Eric Dresselhuys Trustee

2 Please provide the following information concerning each peison oi 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 coipoiation, paitneiship interest in a partnership oi joint venture,

Page 2 of 13

interest ofa member or manager in a limited liability company, or interest ofa 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

Robert Buono 100%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ ] Yes pq No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontr actor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Mattei, as well as the nature of the relationship, and the total amount of the fees paid 07 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 peison or entity who undertakes to influence any legislative or administrative action on behalf of any peison 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 oi administrative action.

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

Page 3 of 13

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

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

to be r etained) lobbyist, etc ) "hourly rate" or "t b d " is

not an acceptable response

(Add sheets if necessary)

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

A COURI-ORDERED CHIL D SUPPORT COMPLIANCE

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

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

[ J Yes Dfl No f J No peison directly or indirectly owns ] 0% or more of the

Disclosing Party

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

[JYes [ j No

B. FURTHER CERTIFICATIONS

I. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e .g., "doing business") and legal r equirements), if the Disclosing Par ty submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Patty certifies as follows: (i) neither the Applicant noi any controlling peison is currently indicted or charged with, or has admitted guilt of, or has evei been convicted oi. or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, per jury, 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 f or doing business with the City NOTE: If Article 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

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

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

c, are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B 2 b. of this Section V;

d have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and

e have not, within a fivc-yeat period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government

The certifications in subparts 5, 4 and 5 concern:

- the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons oi 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 oi ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization ofa business entity following die 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 per son or entity;
any r esponsible of ficial 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 Par ry, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

a bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that of ficer's or employee's of ficial capacity;

b agr eed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement 01 collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or other wise; or

made an admission of such conduct described in a. or b above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-630 (Living Wage Ordinance)

4. Neither the Disclosing Patty, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating

Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U S Department of the Tr easury or the Bureau of Industry and Security of the U S Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.

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

Page 6 of 13

lithe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to die 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 dur ing the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none")

None

9 To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago for purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none") As to any gift listed below, please also list the name of the City recipient.

None

C CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is jX) is not

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

2 Tf the Disclosing Paity 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 pr edatoiy lender within the meaning of Chapter 2-32 of the Municipal Code, explain her e (attach additional pages if necessary):

Page 7 of 13

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

D CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

In accordance with Section 2-156-110 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 pei son or entity in the Mattel?

[ J Yes pq No

NOTE: If you checked "Yes" to Item D.l , proceed to Items D 2. and D.3. If you checked "No" to item D 1. , proceed to Part E

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

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

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

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Mattel 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 Parly 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. 1 he Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury 01 death of their slaves), and the Disclosing Party has found no such records.

2. I he 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 desciibed in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATIERS

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

A. CERTIFICATION REGARDING LOBBYING

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

2 The Disclosing Patty 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 infhience an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee ofa member of Congress, in connection with the award of any federally funded contract, making any f ederally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3 The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occur s any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.

The Disclosing Party ceitilies 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 desciibed in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities"
If the Disclosing Party is the Applicant, the Disclosing Party must obtain cer tif ications 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 subcontractor' 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 oi in writing at the outset of negotiations.

Is the Disclosing Party the Applicant?

f ] Yes [ ] No

If "Yes," answer the three questions below:

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

f 1 Yes [ ] No

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

[ J Yes [ ] No

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

[JYes [JNo

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

Page I Oof 13

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

l he Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in tiiis EDS will become part of any contract oi other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and arc material inducements to the City's execution of any contiact or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations'on which this EDS is based

B The City's Governmental Ethics and Campaign Financing Ordinances, Chapteis 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 ftom 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.

C If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, oi otherwise By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS

E The information provided in this EDS must be kept current. In the event of changes, the Disclosing Pat ty must supplement this EDS up to the time the City takes action on the Matter If the Matter is a contiact being handled by the City's Department of Procurement Services, the Disclosing Paity must update this EDS as the contract lequires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specif ied offenses), the information provided herein regarding eligibility must be kept current for a longer period, as r equir ed by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.l. The Disclosing Patty 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 iowed 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 theii subcontractors to use, any facility listed by the U.S E P. A. on the federal Excluded Parties List System ("EPLS" jj maintained by the U.S. General Services Administration.

F ,3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l - and F.2. above and will not, without the prior written consent of the City, use any such conUactor/subcontractoT that does not provide such certifications or that the Disclosing Party has reason to believe has hot provided or cannot provide trcthful certifications

NO T E: 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 ii

2004 Elizabeth Ci

Irrevocable Trust

Eric P. Dresseihuys

(Print or type name of per sou! signing) Trustee :!

(Print or type title of person signing)

Signed and swom to before me on (date)

at Cook County, i Illinois (state).

Notary Public.

Commission expires: 6>/c^gl/lo

Page 12 of 13

f~ "OFFICIAL SEAL" MytoiimWlenErqif MBMOUf

«tftt/*jfij to wots ,sik»lH f»at<>w

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 inter est 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 ot department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Patty" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic par tner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece ot nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather oi stepmother, stepson or stepdaughter, stepbrother or stepsister' or half-brother or half-sister.

"Applicable Par ty" means (1) all executive officers of the Disclosing Party listed in Section IIB 1 a ., if the Disclosing Party is a corporation; all partners of the Disclosing Paity, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Patty, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Paity, if the Disclosing Party is a limited liability company, (2) all piincipal officers of the Disclosing Party; and (3) any person having more than a 7,5 peicent 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 petson 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 tire elected city official or department head to whom such petson has a familial r elationship, and (4) the precise nature of such familial relationship

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

2300 Partners, LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ J the Applicant

[x| a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: 1601 West Division LLC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: 2300 S. Archer Ave.

Chicago, IL 60616

C Telephone^- 312-636-6937 Fax^- 312-253-4440 Email^- rolando@acostalawpc.com

Name of contact person: Rolando R. Acosta
Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

Rezoning of the property at 1601 15 West Division Street/1148 56 North Ashland Avenue

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

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 of 13

SECTION 11 -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF" THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing [ ] Person

[ ] Publicly registered business corporation [ ] Privately held business corporation [ ] Sole proprietorship [ ] General partnership [ ] Limited partnership [] Trust

Party:

[x] Limited liability company

[ ] Limited liability partnership

I ] Joint venture

[ ] Not-for-profit corporation

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

[ ] Yes [ J No

[ J Other (please specify)

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

Illinois

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

U No

[] Yes

[X]N/A

FJ. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

Name Title

Fred B. Barbara Manager

Page 2 of 13

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

Name Business Address Percentage Interest in the

Disclosing Party

Fred B. Barbara 2300 S. Archer Ave., Chicago, IL 60616 100%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ ] Yes Lx] No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The 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.

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

Page 3 of 13

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

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

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

not. an acceptable response.

(Add sheets if necessary)

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

COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

Disclosing Party.

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

L j Yes [ ] No

FURTHER CERTIFICATIONS

Page 4 of 13

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

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

c. have not, within a five-year period preceding the date of this EDS, been convicted, ad judged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.

The certifications in subparts 3, 4 and 5 concern:

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

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of cither 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 ofa Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

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

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

Page 6 of 13

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

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is IXJ is not

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

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

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

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

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[ ] Yes M No

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

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

Docs the Matter involve a City Property Sale?

[ ] Yes [ ] No

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.

H. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check cither 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 |. The Disclosing Party verifies that the Disclosing Party has searched any and all records of

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

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

Page 9 of 13

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

L J Yes [ J No

If "Yes," answer the three questions below:

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

[ J Yes [ ] No

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

[] Yes [JNo

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

[JYes I J 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

T he Disclosing Party understands and agrees that:

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

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

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

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 Affdiated 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 rickets, property taxes or sales taxes.

NOTE: Tf 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

2300 Partners, LLC

(Print or type name of Di^closi^g Party) By: _

(Sign here) Fred B. Barbara

(Print or type name of person signing) Manager

(Print or type title of person signing)

Signed and sworn to before me on (date) at Coojf CXounry7"^HUrJ°^is--

?//5//3

(state). Notary Piibii*

Page 12 of I!

OFFICIAL SEAL

ANTHONY M KIELAR NOTARY PUBLIC - STATE OF ILLINOIS MY COMMISSION EXPIR£S«1A»16

JA38JAK3PTIO

flAJ3l>) M YMOHTtfA &CMUJI 30 5TAT2 dUBO"? YflATOX 3r«0>.r£r.S.3SiqX3 KC12&MM0D YM

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

L J Yes [XJ No

Page 13 of 13

CJTY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Norwol Corporation

Check ONE of the following thr ee boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [ j the Applicant OR

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

Applicant in which the Disclosing Patty holds an interest:

3 |X! a legal entity with a r ight of control (see Section II B .1.) State the legal name of the entity in which the Disclosing Party holds a right of control: 1601 West Division LLC

Business address of the Disclosing Party: 1910 W. Division

Chicago, IL 60622

C. Telephone: 312-636-6937 £_ax- 312-253-4440 Email: rolando@acostalawpc.com

D Name of contact peison: Rolando R. Acosta

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

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

Rezoning of the property at 1601 - 15 West Division Street/1148-56 North Ashland Avenue

G Which City agency or department is requesting this EDS? 5!!^!^

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

Specification U and Contract #

Vcr 01-01-12

Page 1 of 13

SECTION II -

-DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

[ ] Limited liability company [ ] Limited liability partnership [ ] loint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

[ ] Limited partnership

1. Indicate the nature of the Disclosing Party: [ ] Person [ [ ] Publicly registered business corporation [ XI Privately held business corporation [ [ ] Sole proprietorship [ [ J General partnership (1

[ ] Trust [

[ ] Yes [ ] No

[ ] Other (please specify)

Foi legal en tities, 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?

[]No

[]Yes

DJ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

Robert Buono President, sole officer/director

2. Please provide the following information concerning each pei son 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 shar es in a corporation, partnership interest in a partnership or joint venture,

Page 2 of 13

interest ofa member or manager in a limited liability company, oi interest ofa beneficiary ofa trust, estate or other similar entity. U 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

Rnt»rt Riinun 1910 W. Division S-h., Phinagn, TT, 6063? LQD.%.

SECTION III - BUSINESS RELATIONSHIPS "WITH CITY ELECTED OFFICIALS

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

[ ] Yes DJ No

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

SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor , attorney, lobbyist, accountant, consultant and any other person or 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 Patty is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

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

Page 3 of 13

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

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

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

not an acceptable response.

(Add sheets if necessary)

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

COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[ ] Yes D4 No [ ] No person directly or indir ectly owns 10% or more of the

Disclosing Party

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

[ ] Yes [ ] No

FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-2.3, Article 1 ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of. or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement fordoing business with the City NOTE: If Aiticle 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

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

c. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B 2.b. of this Section V;

d have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and

e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the f ederal government, any state, or any other unit of local government.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;

any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons ot legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "AffiLiated Entity" (meaning a petson 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 contiol include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization ofa business entity following the ineligibility ofa business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, lhe 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 per son or entity;
any responsible official of the Disclosing Paity, any Contractor or any Affiliated Entity or any otbei official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization ofa responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Paity. nor any Contractor, nor any Affiliated Entity of cither the Disclosing Party 01 any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with r espect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five yeats beFore the date of such Contractor's or Affiliated Entity's contiact or engagement in connection with the Matter-:

■d bribed or attempted to bribe, oi been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

agreed or colluded with other bidders or prospective bidders, or been a paity to any such agreement, or been convicted or adjudged guilty of agreement 01 collusion among bidders or prospective bidders, in restraint of freedom of competition by agieement to bid a fixed price or otherwise; or
made an admission of such conduct desciibed in a. ot b above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

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

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

Page 6 of 13

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

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

None

9 To the best of the Disclosing Patty's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Patty 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 tire City of Chicago for purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none") As to any gift listed below, please also list the name of the City recipient.

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

The Disclosing Party certifies that the Disclosing Party (check one) [] is JXJisnot

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

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

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

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

Page 7 of 1.3

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively piesumed 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 Patt D.

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

[ ] Yes |X] No

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

Unless sold pursuant to a process of competitive bidding, or otheiwise permitted, no City elected official or employee shall have a financial interest in his oi hci 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?

[]Ycs I JNo

If you checked "Yes" to Item D.l, provide the names and business addresses of the City of f icials 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 ! 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 enteied into with the City in connection with the Matter voidable by the City

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 Patty verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders desciibed 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 Vll. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City arc not federal funding.

A CERTIFICATION REGARDING LOBBYING

2 The Disclosing Patty 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 ofa member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement

Page 9 of 13

The Disclosing Patty will submit an updated certification at the end of each calendar quarter in which there occur s any event that mater ially affects the accuracy of the statements and information set foith in paragraphs A 1 and A.2 above.
I he Disclosing Party certifies that cither: (i) it is not an organization desciibed in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l through A 4 above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

f .1 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

2 Have you filed with the foint Reporting Committee, the Director of the Office of Federal Contiact Compliance Programs, or the Equal Employment Oppoitunity Commission all reports due under the applicable filing requirements?

[ J Yes [ ] No

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

[ j Yes [ ] No

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

Page 10 of 13

SECTION VII-- ACKNOWLEDGMENT S, CONTRACT INCORPORATION, COMPLIANCE. PENALTIES, DISCLOSURE

The Disclosing Party understands and agtees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract oi other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, ot other City action, and arc material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing PaTty understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based

B The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvorchicaKo.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

C If the City determines that any information provided in this EDS is false, incomplete or inaccutatc. 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 undei the contiact or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Mattel 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 tteblc damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon Tequest. Some or all of the information provided on this EDS and any attachments to this F.DS 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 Patty waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS

E The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Mattel is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract tequires NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified of fenses), 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 II of 13

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

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

F .3 If the Disclosing Party is the Applicant, the Disclosing Par ty 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 !^;.l. and f.2. above and will net, without the prior written consent of the City, use any such contractor/suDCODtractor that does not provide such certifications or that the Disclosing Patty 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 peison signing below. (1) warrants thai he/she is authorized to execute this E DS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that ail certifications and statements contained in this EDS and Appendix A (if.applicable) arc true, accurate and complete as of the date furnished to the City.

Norwo! Coiporation (Ptint ftr type name o£J2^c]osing Party)

(Sign here)

By:

Robert Buono

{'Pi int or type name of person signing)

Presideni

("Print or type title of-person signing)

Signed and swain to before me on (date) lil&l

^at Cook County, Illinois (state).

Notary Public

Coram ission expires: (j>/^&) l&

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

"Applicable Paity" means (1) all executive officers of the Disclosing Party listed in Section II.B.l a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Paity is a limited partnership; all managers, managing members and members of the Disclosing Paity, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Patty; and (3) any peison 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 peison exercising similar authority

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

[ ] Yes [XJ 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 tide 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 SI A 1 EtVIENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A. Legal name of the Disclosing Patty submitting this EDS. Include d/b/a/ if applicable: Newgard Development LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Paity submitting this EDS is: 1. [] the Applicant OR

2 [)5 a legal entity holding a direct oi indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest: 1601 West Division LLC OR

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party:
Telephone: 312-636-6937 p_ax: 312-253-4440 Email: rolando@aCQStalawpc.com

D Name of contact peison: Rolando R. Acosta

E. federal Employer identification No. (if you have one):

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

Rezoning of the property at 1601 - 15 West Division Street/1148 - 56 North Ashland Avenue

G Which City agency or department is requesting this EDS? unuu

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

Specification # and Contract #

vcr ot-or-12

Page 1 of 13

SECTION II -

-DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1 Indicate the natute of the Disclosing Patty: [ ] Peison [)

[] Publicly registered business coipoiation [

[ ] Privately held business corporation [

[ ] Sole proprietorship [

[ ] General partnership (]

I ] Limited partnership

Limited liability company [ ] Limited liability partnership [ ] loint venture [ ] Not-fbi-profit corporation (Is the not-for-profit corporation also a 501(c)(3))'?

[ ] Yes [1 No

[ ] Other (please specify)

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

Illinois

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

[]No

[] Yes

MN/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing mcmbei, manager or any other peison 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

Paul Utigard Manager

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7 5% of the Disclosing Party F.xamples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.

Page 2 of 13

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

Name Business Address Percentage Interest in the

Disclosing Party

Paul Utigard 1341 W. Fullerton, Chicago, IL 60614 42.5%

DanaUtigard 1341 W. Fullerton, Chicago, IL 60614 42.5%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

L j Yes M No

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

SECIION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Paity 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 requited to disclose employees who arc paid solely thtough 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 whethei a disclosure is required under this Section, the Disclosing Party must cithei 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.) NOIE:

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

not an acceptable response

(Add sheets it necessary)

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

COURf-ORDERED CHILD SUPPORT COMPLIANCE

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

[ ] Yes |X] No [ ] No peison directly or indirectly owns 10% or more of the

Disclosing Party

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

[ ] Yes [ ] No

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 this EDS is the Applicant and is doing business with the City, then the Disclosing Patty certifies as follows: (i) neither the Applicant not any controlling person is currently indicted or charged with, or has admitted guilt of, or has evet been convicted of, or placed under super vision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, per jur y, dishonesty or deceit against an officer or employee of the City or any sistci agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below

Page 4 of 13

2. The Disclosing Patty and, if the Disclosing Party is a legal entity, all of those persons oi entities dcnlificd in Section II B 1. of this EDS:

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

c. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B 2 b. of this Section V;

d have not, within a five-year period preceding the date of this EDS, had one or mote public transactions (federal, state or local) terminated for cause or default; and

e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.

3 The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;

any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the 'Matter, including but not limited to all persons oi legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a petson or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization ofa business entity following the ineligibility 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 Paity. nor any Contractor, nor any Affiliated Entity of cither 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 ofa Contractor during the five years before the date of such Contractors ot Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, oi been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any .state or local government in the United States of America, in that officer's or employee's official capacity;

b agreed or colluded with other bidders or prospective bidders, or been a patty 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 agieement to bid a fixed price or otherwise; ot

c. made an admission of such conduct desciibed in a ot b above that is a matter of record, but have not been prosecuted lot such conduct; or

d violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance)

4. Neither the Disclosing Party. Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of'(l) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar of fense of any state or of the United States of America that contains the same elements as the of fense of bid-rigging or bid-rotating

5 Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U S Department of the Treasury or the Bureau of Industry and Security of the U S Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.

The Disclosing Parry understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of The Municipal Code
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Fuithci Certifications), the Disclosing Party must explain below:

Page 6 of 13

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

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

9 To the best of the Disclosing Par ty's knowledge after reasonable inquity, the following is a complete list of all gifts that the Disclosing Party has given or caused ro be given, at any time dur ing 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 pur poses of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none") As to any gift listed below, please also list the name of the City recipient.

None

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

f .1 is W ^,s ¹⁾⁰¹

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

2. If the Disclosing Paity 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 piedatory lender as def ined in Chapter 2-32 of the Municipal Code We understand that becoming a predatory lender or becoming an affiliate of a predatory lendermay result in The loss of the privilege of doing business with the City."

If the Disclosing Par ty 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 predatoiy lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page ? of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively ptesumed 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 Patt 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 peison or entity in the Matter?

[]Yes fXjNo

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

2 Unless sold putsuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a f inancial interest in his or hci own name or in the name of any other pei son 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

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

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 L or 2. below. If The Disclosing Party checks 2., the Disclosing Paity must disclose below or in an attachment to this EDS all information tequired by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure lequiiemeiits 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 dining the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of thc.it slaves), and the Disclosing Party has found no such records

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

Disclosing Party has found records of investments or prof its 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 MAT 1 ERS

NOT E: If the Matter is federally funded, complete this Section VI If the Matter is not federally funded, proceed to Section Vll For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City ate not federal funding.

A CLRIU ICAIION REGARDING LOBBYING

(if no explanation appears or begins on the lines above, or if the letters "NA" or if the wotd "None" appear, it will be conclusively presumed that the Disclosing Patty 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 tespect to the Matter )

2 The Disclosing Patty has not spent and will not expend any federally appropriated funds to pay any peison oi entity listed in Paragraph A 1. above for his or her lobbying activities or to pay any peison or entity to influence or attempt to influence an officer or employee ot any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congtess, or an employee ofa member ol 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, lenew, amend, or modify any federally funded contiact, grant, loan, or cooperative agreement.

Page 9 of 13

3 I he Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A 1 and A 2 above

4. The Disclosing Party certifies that cither: (i) it is not an organization desciibed 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 19S6 but has not engaged and will not engage in "Lobbying Activities"

5 If the Disclosing Patty is the Applicant, the Disclosing Party must obtain cettifications equal in form and substance to paiagraphs A.l thiough A 4. above from all subcontractor befoie it awaids any subcontract and the Disclosing Party must maintain all such subcontractor' 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, fedetal 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 Patty the Applicant?

1 ] 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.)

MYes I j No

2 Have you filed with the foint Reporting Committee, the Diiectoi of the Office of'Fcdcral Contiact Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

IJ Yes [ ] No

3. Have you paiticipated in any picvious contiacts or subcontracts subject to the equal oppoitunity clause?

[ j Yes [ ] No

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

Page 10 of 13

SECTION VII -- ACKNOWLEDGMENT S, CONTRACT INCORPORATION, COMPLIANCE. PENALTIES. DISCLOSURE

The Disclosing Patty unrieistands and agrees that:

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

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

C If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contr act or agreement (it not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Mattel 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 tteblc damages.

It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some oi 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 Patty waives and releases any possible lights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up lo the time the City takes action on the Matter. If the Matter is a contiact being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract tequires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regaiding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code,

Ihe Disclosing Party represents and warrants that:

Page 11 of 13

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

F .2 If die Disclosing Party is the Applicant, the Disclosing Par ty and its Affiliated Entities will not use, nor permit their subcontractors to use, .any facility listed by the U.-S E PA. 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 ths Matter certifications equal in form and substance to those in F:.L and F2. above and will not without the prior written consent-of the City, use any such contractor/subcontractor that doss 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 Patty cannot certify as to any of the items in f.l., F.2. orf 3. above, an explanatory statement must be attached to this EDS-

CERTIFICATION

Under penalty oi perjury, the person signing below: (1) warrants that he/site 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.

Newgard Development LLC

(Prin t or type name of Disclosing Par ty)

Manager

(Print ot type title of peison signing)

Count v, Illinois

Signed and sworn to before me on (date) at Cook

(state)_:Notaiy Public.

Commission expires:

Page 12 of 13

._|f,-. ww»w»*»^

' JA33 JADHW

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAV1I APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to he 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 owner ship 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 curr ently has a "familial relationship" with any elected city official ot department head. A "familial relationship" exists if, as of the dale this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city cleik, the city treasurer or' any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, biothei or sistet, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather 01 stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l a., if the Disclosing Party is a corporation; a.11 partners of The Disclosing Patty, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Patty, if the Disclosing Paity is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any petson having mote than a 7.5 percent ownership interest in the Disclosing Parly. "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 oi department head?

[ ] Yes [_Xl No

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Westgate Acquisitions, LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

[ ] the Applicant

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

Applicant in which the Disclosing Party holds an interest: 1601 West Division LLC

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

which the Disclosing Party holds a right of control:

Business address of the Disclosing Party: 3215 W. Fullerton

Chicago, IL 60647

Telephone: 312-636-6937 p_ax; 312-253-4444 Email: rolando§acostalawpc.com
"Name of contact person: Rolando R. Acosta
Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

Rezoning of property at 1601 - 15 West Division Street/1148 - 56 North Ashland Avenue

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

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

Specification ft and Contract #

Ver. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing [ J Person

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

Party:

|x] Limited liability company

[ ] Limited liability partnership

[ ] Joint venture

[ ] Not-for-profit corporation

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

L J Yes [ ] No

[ ] Other (please specify)

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

Illinois

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

[] Yes

□ No

be] N/A

13. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

Name Title

Mark A. Fishman Manager

Page 2 of 13

Name Business Address Percentage Interest in the

Disclosing Party

Mark A. Fishman 3215 W. Fullerton Ave., Chgo, IL 60647 100%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the M unicipal 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 AND OTHER RETAINED PARTIES

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

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

Page 3 of 13

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

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

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

not an acceptable response.

(Add sheets if necessary)

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

COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

Disclosing Party.

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

[ ] Yes L J No

FURTHER CERTIFICATIONS

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

Page 4 of 13

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:

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

the Disclosing Party;

any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization ofa 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 ofa Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

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

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

Page 6 of 13

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

None

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

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [XI is not

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

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

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

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

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[ ] Yes kj No

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

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

Does the Matter involve a City Property Sale?

[ ] Yes [ j No

If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify 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. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

A. CERTIFICATION REGARDING LOBBYING

Page 9 of 13

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

501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Is the Disclosing Party the Applicant?

[]Yes []No If "Yes," answer the three questions below:

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

[ ] Yes [ ] No

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

[]Yes []No

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

[]Ycs []No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

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

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

If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Parry's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this E.DS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1 -23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

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

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

Westgate Acquisitions, LLC

(Print or type

By:

(Sign here)

Mark A. Fishman

(Print or type name of person signing)

Manager

(Print or type title of person signing)

Notary Public.

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.S percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

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

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

L j Yes [XJ No

If yes, please identify below (I) rhe 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

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EFORE building by same and at rotor to your abstract, doad,

§ llnate Datum If usod Is ASSUMED.

ORDERED BY: 1601VI. DIVISION LLC IICHEC		KED:	DRAWN: RL/BB
ADDRESS: 1601 W. DIVISION STREET II
GREMLEY & BlEOERMANN < I PLCS, Corporation I License No. 111-005322 Phofessknal Lano sumtms 1505 North Elston Avenue, Chicago, IL 60630 TELEPHONE: (773) 685-5102 FAX: (773) 286-i.Ul EMAIL: INFO»PLCS-SURVEY			\m COM
ORDERNO. 2013-18043-001	DATE: JULY 15, 2013	PAGE NO. 1 OF 1

G:\CAD\2011\2O11-l5308\2013-18043-00t.dwg

SURVEY NOTES:

Note R. & M. denotes Record and Measured dlsta

Distances are marked in feet and decimal parts tfr once report any differences BEFORE damage is d

For easements, building lines and other restriction contract, title policy and local building line regulatk

NO dimensions shall be assumed by scale measu

Monumentation or witness points were not set at tt

Unless otherwise noted hereon the Bearing Basis.

COPYRIGHT GREMLEY & BIEDERMANN, INC. '<

Legislation Text

Legislation Details

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