I
SUBDIVISION ORDINANCE
Be it Ordained by the City Council of the City of Chicago:
SECTION 1. Chicago Department of Transportation, the Commissioner or his assigners, is hereby authorized and directed to approve a proposed Aldi O'Reilly Subdivision; being a subdivision in the block bounded by S. Indianapolis Boulevard, S. Avenue B and E. 106th Street and legally described in the attached plat (Exhibit A, File:08-10-13-3605) which, for greater certainty, is hereby made a part of this ordinance.
SECTION 2. The subdivision herein provided for is made upon the express condition that within one hundred eighty (180) days after the passage of this ordinance, HAL Series Acquisition, LLC Skyway and 4000 E. 106th St., LLC shall file or cause to be filed for record in the Office of the Recorder of Deeds of Cook County, Illinois a certified copy of this ordinance, together with the attached Plat approved by the Department of Transportation / Superintendent of Maps.
SECTION 3. This ordinance and exhibit subdivision plat shall take effect and be in force from and after its recording.
-P.
ft
Honoralj Alderm«
A-
)hn Pope Dth Ward
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY 1. Indicate (he nature of the Disclosing Party:
tK! Person [}
i" "i Publicly registered business corporation [ ]
[ ] Pnvatsly held businesr corporation [ ]
[) Sole proprietorship [ j
[ ] General partnership (Is
I) Limited partnership
I j Trust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
tbe not-for-profit corporation also a 501(cX3)J?
[JYes [JNo Other (please specify)
For legal entities, the suite (or foreign country) of incorporation or organization, if applicable:
3. For lega.i entities no: organized in the State of Illinois: Has the organization registered lc do business in the State of Illinois as a foreign entity?
r ■■ Vcs [ ] No [) N/A.
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. Lisi belou :hf full names and titles of all executive officers and all directors ol rhe emit). NOTE: For noi-for-profit corporations, also list below all members, if any, which are legal entities. If there arc no such members, write "no members." For trusts, estates or other similar entities, list below Che lega: tit)eho]dcr(sl.
If the emit- is s general partnership. limited partnership, limited liability company, limited liability partnership or join; venture, list below the name and title of each general partner, managing member, manager or am other person or entity that controls the day-to-day management of the Disclosing Parry. NOTE: Each iega! cntitv iisied below must submit an EDS on its own behalf.
Name T'\r\r
N/A 1
2. Please provide tbe following information concerning each person or entity having a direct or uidtrect beneficial interest (including ownership) in excess of 7.5% of tbe Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code uf 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 tbe
D:--'--.ing Party
SECTION III -- BUSINESS RELATIONSHIPS W ITH CITY ELECTED OFFJCLvLS
Has the Disclosing Party had a "business relations nip," as definec in Chapter 2-156 of the Municipal Code, with any Cit> elected official in tbe 12 months before the date this EDS is signed'*
rjvej p?\o
If yes. please idemi!> below th: nameiM of such City elected official(s) and describe such relationships si:
SECTION JV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party mus: cisciose 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 conuection with the Matter, as well as the nature ofthe relationship, and the total amount of the fees raid or estimated to be paid. The Disclosing Party is not required to disclose employers who are piid solely through the Disclosing Parry's regular payroll.
"Lnbhy'ts;" means any person or entity' who undertakes to influence any legislative or administrative action on behalf of an> person or entity other than: (Da not-for-profit entity, on an unpaid ba.*is, or (2, himself. "Lobbyi*:'' also means any person or entity any part of whose duties as an employee of another include! 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 m ust either ask the City whether disclosure is required or make me disclosure
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.Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney. paid or estimated.) NOTE:
to r>e rstaineo.) lobbyist, etc.) "hourly rale" or *t >.&." is
not an acceptable responds.
None
(Acid sheets if necessary)
[>9 Check here if the Disclosing Part)' has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415. substantial owners of business entities :ha: contract with the City must remain in compliance with their child support obligations throughout the contract's term
Hasan} person who directly or indirecti) owns 10% or more of tbe Disclosing Part}- been declared in arrearage on any chiic support obligations by en> Illinois court of competent junsdicuon?
| ] Y e* H \:o [ ] No person directly or indirectly owns J 0% or more of the
Disclosing Party.
If "Yes " has the person entered into a court-approved aereeroeni for paymenl of all support owed and is :he person in compliance with that agreement?
t.iVss IJNc
B FURTHER CERTIFICATIONS
1. Puxsuani 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 rhis EDS is the Applicant and is doing business with tbe City, then the Disclosing Party certifier 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 lo commit bribery, theft, fraud, forgery, penury, dishonest} or deceit against an officer or employee of tbe City or any sister agency; and (ii) the Applicant understands and acknowledges tbat compliance with Article I is a continuing requirement i*or doing business with the City. NOTE: If Article J applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
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Z. The Disclosing Party and. if the Disclosing Parry is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
c 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:
b have not. w ithin z five-year period preceding tbe date of this EDS. been convicted of i criminal offense, adjudged guilty, or bad a cjvi! judgment rendered against them in connection with' obtaining, attempting to obtain., or performing a public (federal, slate 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 no", presently indicted for, or criminally or civilly charged by. a governmental entity (federal, state or local'i with committing any of the offenses sei forth in clause B.2.b. of this Sec:ior. V.
d h3v» no'., within a five-year period preceding the date of this EDS. had one or more public transactions (federal, state ot local) terminated for cause ot default; and
e have not. within a five-year period preceding the date of this EDS. beer, convicted, adjudged guilty, or found liable tn a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government. an> state, or any other unit of local government.
3. The ccr:tfications in subparts 3. 4 and * concern
- the Disclosing Parry
- any -Contractor'' (meaning any contractor or subcontractor used by the Disclosing Party m connection with the Matier. including bui Dot 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 Pany. 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 intercsrs among family members, shared facilities and equipment; common use of employees: or organization of a business entity following the ineligibility oft business entity to do business with federal or state or local government, including theCtry. using substantially the same management, ownership, or principals as the ineligible entity v with respeci to Contractors, the term Affiliated Entity means a person or entity thai directly or mdirec.ly 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 Pany, any Contractor or any Affiliated Entity or any other official, aeeni or employee of the Disclosing Parry, any Contractor or any Affiliated Entity, acting pursuani to the direction or authorization of a responsible official of the Disclosing Parry, any Contractor oj any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Part), nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any A gents have, during the five years before the date this EDS is signed, or. with respec: id s Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during che five years before the dale of such Contractors or Affiliated Entity's contract or engagement tn connection with the Matter:
i bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency of the federal govemmen". or of an? state or local government in the United Stales of America, in mat officer s or employee s official capacity.
b. agreed or colluded with olher bidders or prospective bidders, or been apart} to any such
agreement, or been cocvicied or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement 10 bid a fijeec price or otherwise, or
c made zr. ndtr.issirin of such conduct described in e or b. above that is a matter t'X record, bur have no! been prosiecuted for such conduct: or
d. vioialed rhe provisions of Municipal Code Section 2-u2-6)0 (Living Wage Ordmancei
- Neither the Disclosing Party. Affiliated Emily or Contractor, or an> of their employees, officials, agents or partners. 15 barred from contracung with any unit of state or local government as a result of engaging in 01 being convicted of 111 bid-rigging in violation of 720 ILCS 5/33E-3; (2' bid-rotating ir. violation of 720 ILCS 5 33E-'1: or (31 any similar offense of an} state or of the United States o: America thai containf the same elements as the offense of bid-rigging 01 bid-rotating
- Neither the Disclosing Part} nor an} Affiliated Entity is listed on any of the following lists maintained b> the Office of Foreign Assets Control of the U.S. Department ofthe Treasury or tbe Bureau of Industry and Security of theU.S Department of Commerce ot their successors: the Special!) Designated Nationals Lis;, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
6 The Disciosmg Pany understands and shall compl} with tbe 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 Pan B (Further Certifications), tbe Disclosing Party must explain below:
N/A
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If the letters "NA.'' the wore "None." or no response appears on the lines above, it will be conclusively p.-esumsd thai chr Disclosing Party certified to the above statements
S. To the best o: the Disclosing Parry's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date o: this EDS, an employee, oi elected or appointed official.
of the Civx ff ChJcaco (if none, indicate with "N 'A' or "none").
N/A
9 To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete lis: of al! gifts :bai the Disclosing Party has given or caused to be given, at any time during the i2-roonth period preceding rhe execution date of th:s EDS. to as employee, or elected or appointed official, of the Ciry of Chicago. For purposes of this statement, a "gift" does not induce: l il anything made rcr.srclh : vail able lo City employees or to the general public, or (ii) food ot drink provided is the course of official Ciry business and having a retail value of less than S20 per recipient i'i.r none, indicate with "N A" or "none"! *s 10 anj girt iistec beion . please also list the name o: the City recipient
ICTS" ■
C CERTIFICATION Ol' ST ATI'S AS FINANCIAL INSTITUTION
I The Disclosing Parii certifies tha; the Disclosing Party icheck one''
[ ] is ?0 ii noi
i "financial institution" as defined in Section 2-32-45 5(b) ofthe Municipal Code.
1. Jf the Disclosing Parry IS a financial institution, then the Disclosing Party pledges
"We are no< anc u ill not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a precatory lender as defined Id Chapter 2-32 ofthe Municipal Code. We understand thai becoming a predatory lender or becoming an affiliate of a predatoTy lender may result in the loss of the privilege of coma business with the City."
I: the Disclosing Pany is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-4 55(b > of tbe Municipal Code) is a predatory lender within tbe meaning of Chapter 2-32 of ihe Municipal Code, explain here (attach additional pages if necessary)
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:." the lertsrs "NA." the wore ''None.'' or no response appears on the lines above, it will be conclusive!) presumed that lbs Disclosing Parry certified to the above statements.
D CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
I !n accordance with Section 2-156-110 of the Municipal Code: Does any official or employer ofthe Ciry have a financial interest in his or her own name or in the name of any other person or cntiry in the Matter"
:". Yes [X\o
NOTE' 1; you checked "Yes" to Item D I., proceed to Items D.2. and D.3. If you checked "No" to Item D.: proceed to Pan E.
2. L mess solo pursuant to t 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 cntiry in the purchase of any pToprrty that (i) belongs lo the City, or (rl) is sold for raxes or assessments, or uii) it sold by virtue of legal process a', the suit of the City (col)ec.i\ ely. "Ciry Properr> Sale"). Compensation for property taken pursuant to the City's emment domain power does noi consuiuir z fintnciai interest within the meaning of this Part D
Does the Matter involve z City Property Sale?
[}Yes No
:■ If you checked ",vi es' 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
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. belou . If tbe Disclosing Party checks 2., the Disclosing Party must disclost below or in an attachment to this EDS all information required by paragraph 2. Failure to
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comply with these disclosure requirements may make any contract entered into with thr City in connection w ith the Matter voidable by the City.
x :. Trie Disclosing Party verifies that the Disclosing Parry has searched any and all records of the Disclosing Part) and any and al! predecessor entities regarding records of investments or profits frorr. slavery <>r slaveholder insurance policies during the slavery era (including insurance policies issued ro slaveholder? that provided coverage for damage to or injury or death of their slaves), and the Disclosi-!.' Part; has found no such records.
2. The Disclosing Party verifies that, as a result o: conducting the searcii in step 1 above, the
D.sclosinc Party has found records of investments or profits from slavery oi slaveholder msurancr policies The Disclosing Parry verifies that the following constitutes full disclosure of Mi such records, mcluding the names of any and all slaves or slaveholders described it those records:
N/A
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Miner is federally fuDded. complete this Section VI. If tbe Matter u not federally funded, proceed \p Sectior. VII. For purposes of this Section VI, -.a* credits allocated by the City and prooeccs ; ;* dtb. obligations ofthe City are no: federal funding
A CERTfFlO *>T10N REGARDING LOBBYING
Lis: bclou ;b? name.1 of all persons or entities registered under the federal Lobbying Disciosurr Aci c: 1Vv5 who have made lobbying contact; on behalf ofthe Disclosing Party with respect tc the Mattrr- ;Add sheets if necessary V
iTTa '
(If no explanation appears or begins on tbe lines above, or if the letters "NA" or if the word "None" appear, it w;i| be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Ac; of 1995 have made lobbying contacts on behalf ofthe 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 psrsor. or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law. a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement
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3. The Disclosing Parry will submit an updated certification at the end of each calendar quarter in which there occur* any even; that materially affects the accuracy of the statements and information set form in paragraphs A.l. and A.2. above.
■- The Disclosing Party certifies that either: (i) it is not an organization described in section 5P'(cH41 of the Internal Revenue Code of 1986: or (iii it is an organization described in section SOKcX^I ofthe Internal Revenue Code of 1986 but has not engaged and will not engage ir. "Lobbying Activitic5".
5. IT 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 Parry 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. CERTIF!C <\T!0\ R.ECRDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matte; is federally funded, federal regulations require tbe Applicant and all proposed subcontractors to submit the following information with their bids oi in writing ai the outsei Df negotiations NOT FEDERALLY FUNDED
Is tbe Disclosing Party the Applicant'/
[1Ye< |}No
If "Ycs.v art.^-wer ihe three questions nclow.
- Have you developed and do you have on f.le affirmative action programs pursuant to applicable federal regulations" (See 4 I CFR Part 60-2.')
f 1 Yes" { ] No
- Have you filed with the Joini Reporting Committee, the Director ofthe Office or Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
I 1 Yes [ ] No
- Have you participated in any previous contracts or subcontracts subject to chc equal opportunity clause?
I] Yes ' []No
If you checked "No" to question I. or 2, above, please provide an explanation: N0T FEDERALLY FUNDED
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SECTION VII- ACKNOWLEDGMENTS. CONTRACT INCORPORATION. COMPLIANCE. PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
- The ccntficaiion*. disclosures, and acknowledgments contained in mis EDS will become pan of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistaocc, or other C iry aciion, and are material inducements to the City's execution of any contract oi taking other action with respect to the Matter. The Disclosing Party understands thai it must compij 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 od persons or entities seeking City contracts, work, business, or transactions. Tbe full text of these ordinances and a training program is available on line ai www.citvofchicago.org'Etbics. and may also be obtained from the City's Board of Ethics. "40 N.
Sedgwick St Suite 500 Chicago. IL 60610. (3121 744-9660. The Disclosing Parry must comply fu)l> with the applicable ordinances.
- If the City ocicrm:ncs :hai any information provided in this EDS is false, incomplete or inaccurate, any contract or orhcr agreement in connection with which n 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 i. at law. or :ri equirv. including terminating the Disclosing Party's participation in the Matter and/or declining to alio* rhe Disclosing Parry to participate in other transactions with the City. Remedies a-"law- for a raise siatcmeni of materia: fact may include incarceration and an award to the City of treble damages
- It is the Citys policy lo make this document available to tbe pubiic on its Internet site and'or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available 10 the public on the Inicraei. in response to a Freedom of Information Aci request, or otherwise. By completing and siEDine 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 inforraanon contained in this EDS and also authorizes the Ciry to verify the accuracy of any information submitted in this EDS.
- The information provided in this EDS roust be kept current. In tbe event of changes, tbe Disclosing Parry must supplement this EDS up to tbe time tbe 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 I -23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kepi current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
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F.l. The Disclosing Parry is nol delinquent in the payment of any tax administered by the Illinois Department of Revenue, not are the Disclosing Pany or its Affiliated Entities delinquent in paying any fine, fee. ta>; or other charge owed to the City. This includes, but is not limited to, all R'arer charges, sewer chargu&. license fees, parking tickets, property taxes or sales taxes.
F.2 ll" the Disclosing Party is the Applicant, the Disclosing Parry and its Affiliated Entities will no: 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. Genera! Services Administration.
F.3 If the Disclosing Party is the Appiicant, The Disclosing Party will obtain from any contractors'subcontractors hired or to be hired in connection with tbe Matter certifications equal in form and substance to those in F. 1. and F.2. above and will not, withoui the prior written consent of the City, use any such contractor'subconlructor thai does not provide such certifications or that the Disclosing Party has reason to believe bas not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items tr. F.l F.2. or F.3 above, tr. explanatory statement must be attached to this EDS.
CERTIFICATION
Under penchy of penury, the person signing below: (I) warrants that he/she is authorized to execute this EDS and Appendix A (iT applicable) on behalf of the Disclosing Party, and (2) warrants thai all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the dale furnished to the City,
(Pnntnr tvncogme.oXPL'icUjsine Party).
Randall danger
('Print or type name of person signing)
(Print or type title of person signing)
County. TUt r>v; :i> (state).
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT .AND AFFIDAVIT APPENDIX A
FAMILIAL RELATIONSHIPS WTTH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only b> (a) the Applicant, and fb) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is dot 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 Pany must disclose whether such Disclosing Parry or any "Applicable Pany" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city offtciai or department head. A "familial relationship" exists if, as of the date thus 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-io-law, son-m-law, danghtcr-in-low. siepfalbcr or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sistet.
'Applicable Parry" means IT.I all executive officers of the Disclosing Party listed in Section D.3. l.a. if the Disclosing Parry is a corporation; all partners ofthe Disclosing Party, if the Disclosing Parry is a genera; partnership- all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limiiec partnership: all managers, managing members and members of the Disclosing Party, If the Disclosing Party is e limited liability company; (2) all principal officers of the Disclosing Parry, and (?) 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 or a legal entity or any person exercising similar authority.
Docs the Disclosing Parry or any Applicable Party" or any Spouse or Domestic Partner thereof currently have a "famuia! relationship'' with an elected city official or department head?
( ] Ycf [X) No
I f yes. please identify below f I i the name and title of such person, (2) the name of tbe legal entity to which such person is connected: (3) the name and title of the elected city official or department best! lo whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
I. Indicate the nature of tbe Disclosing
5 Person
) Publicly registered business corporation
] Privately held business corporation
j Sole proprietorship
] General partnership
] Limited partnership
j Trust
[Jj Limited liability company
[ } Limited liability partnership
[ J Joint venture
[ ] Noi-for-profn corporation
(Is tbe not-for-profit corporation also a 501(c)(3))?
[ ) Yes [ } No
(] Other (please specify)
2 For legal entities., the state (or foreign country) of incorporation or organization, if applicable: Illinois
3. For legal entities no: organized in the State of Illinois- Has tbe organization registered to do business in the State of Illinois as a foreign entity?
;jYcs {]No [jN.'A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List belou 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 arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal utleholdcr(si.
Title
Manager
If the entity is i genera) partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the came and title of each general partner, managing member, manager or any other person or entity thai controls the day-to-day management of tbe Disclosing Party. NOTE: Each iega! entity listed below must submit an EDS on its own behalf.
Name
Randall Langer
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 tbe Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None" NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
None ■
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 pq No
If yes. please identify belnu the ruuneisi of suet Ciry elected officials) and describe such relarionshiplsr
SECTION JV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Parry must disciosr the nam: and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects u< rrrain in connection u irh the Matter, as well as the Dature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Parry is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist' means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than- (11 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 tbe disclosure
Page 3 of 13
Name findicate whether Business Relationship to Disclosing Party Fees (indicate whether
retBincd or a;uicipaird Address (subcontractor, attorney. paid or estimated.) .NOTE:
to r>e retained) lo'nhyist. etc.) "hourly rate" o.-'"t.b.d." is
not an acceptable response.
None
(Add sheets if necessary)
P5 Check here if the Disclosing Parry has not retained, nor expects to retain, any such persons or entities SECTION V _ CERTIFICATIONS
A COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Mumcipa. Code Section 2-y2-4J5. substantial owners of business entities tha: contract with the Cir* roust remain in compliance with their child support obligations throughout the contract's term.
Mas any person who ciirrctiy or indirectly owns 10% or more of the Disclosing Parry been declared in arrearage on any chiic support obligations by any Illinois coun of competent jurisdiction?
| ) Y es J3} 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?
i i ^ w I J
B FURTHEK CERTIFICATIONS
J Pursuant to Municipal Code Chapter 1-23. Article I ("Article l"X*'bicb 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 certifiB? as follows. (!) 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 tbat compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article 1 applies to tbe Applicant, tbe permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below
Page 4 of 13
2. Tbe Disclosing Party and. if the Disclosing Party is a legal entity, all of those persons o: entities identified in Section II.B.l. of this F.DS:
a. are noi presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unn of government;
b have not. wirhin c five-year penod preceding the date of this EDS. been convicted of a criminal offense, adjudged guilry, 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; maictng false statements: or receiving stolen property:
c. are no: presently indicted for. or criminally or civilly charged by. a governmental entity I federal, stale o: locali with committing any ofthe offenses set forth in clause B.2.b. of this Section V.
d have rot. wuh;n a fi\ e-year period preceding the dale of this EDS. had one or more public transactions (federal state or local) terminated for cause or default; and
e. have rot. within a five-year period preceding the date of this EDS. beer, 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, oi any other unii of local government
j. The ccr:ificanon>- in subparts 3. 4 and * concern'
ihe Disclosing Party
» any ''Contractor" (meaning any contractor ot subcontractor used by the Disclosing Party in connection with the Matiet. including but not limited to all persons or legal entities disclosed tinder Section IV, "Disclosure of Subcontractors and Other Retained Parties").
- any "Affiliated Entity" (meaning a person or entity that, directly ot indirectly: controls the Disclosing Party, is controlled by the Disclosing Pany. or is. with the Disclosing Pany. under com mo r. control of another pcrsoc or entity. Indicia of control include, triihout litnilatior interlocking management or ownership: identity of interests among family members, shared facilities and equipment: common use of employees; or organization of a business eatiry following the ineligibility of e business entity to do business with federal or state ot local government, including the Ciry. 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 ofthe Disclosing Pany, any Contractor or any Affiliated Entity or any other official, agent or employee of the D isclosing 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 Part), nor any Contractor, no; 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 resoec it's Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during tbe five years before the date oTvuch Contructor'i or Affiliated Entity's contract or engagement in connection with the Matter.
i bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bnbc. a public officer or employee of the City, the State of Illinois, or any agency of tbe federal government or of any state or local government in tbe United States of America, in thai officers or employee's official capacity:
b agreed or colluded with other bidders or prospective bidders, or been a party lo any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of fieedom of competition by agreement to bid a fined pnee or otherwise- or
c. made er. admission of such conduct described in a or b. above that is a matter of record bir. have no: been prosecuted for such conduct- or
d violated the provisions of Municipal Code Secnon 2-92-6)0 (Living Wage Ordinance).
a Neither the Disclosing Parry. Affiliated Entity or Contractor, or any of their employees, officials, agents ot partners. IS barred from contracting with any unil of slate or local government as a rtsull of engaging in or being convicted of (11 bid-rigging in violation of 720 ILCS 5/33E-3; (2* bid-rotating :r violation of ?20 ILCS 5 '33£-<l; or f 3) any similar offense of any state or of the United Stale: of America thai contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Pany nor any Affiliated Entity is listed on any of the following lists maintained by the Office ofForeign Assets Control of the U.S. Department ofthe Treasury or ibf Bureau of Industry and Security of the U.S Department of Commerce or their successors: the Specially Designaied Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List
6 The Disclosing Pany understands and shail comply with ibe applicable requirements of Chapters 2-55 (Legislative Inspector General!. 2-56 (Inspector General) and 2-156 (Governmental Ethics,' of the Municipal Code
"5. )f the Disclosing Pany is unable to certify \o any of the above statements in this Part B (Further Cenifications). tbe Disclosing Pany must explain below:
N/A
Page 6 of 15
If the letters 'NA.' the wore "None." or no response appears on the lines above, it will be conclusively nrcsumsd tha: :hr Disposing Parry certified to the above statements.
fc. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the. following i; a
complete list of al! current employees of the Disclosing Party wbo were, at any time during tbe 12-
raonth period preceding the execution date o: this EDS. an employee, or elected or appointed official.
of the Ci',\ ct* Chicaco (if none, indicate with "N 'A " or "none"). N/A
9 To tht besi of tbe 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-raontli period preceding tbe execution date of this EDS. 10 an employee, or elected or appointed official, ot the Ciry of Chicago. Fot purpos-es of this statement, a "gift" does not induce: (il anything made gcr.rrcl'.y tvailable to City employees ot to the general public, ot (ii) food oi drink provided in the course of official Ciry business and having a retail value of less than S20 per recipient (if none, indicate with "N A" or "none"i. As 10 any gift 'listed below please also lis: the name ofthe City recipient.
K77T
C CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Pany certifies tha; the Disclosing Party (check one
' ] if ?\l is> noi
2 "financial institution" as defined in Section 2-?2-455(bi of the Municipal Code.
2 If Lit Disclosing Parry IS a financial institution, then the Disclosing Pany pledges:
"We are noi and w ill not become a predatory lender as defined in Chapter 2-22 ofthe Municipal Code. V»'e further pledge that none of our affiliates is. and none of tbem will become, a predator, lender as defined in Chapter 2-32 of the Municipal Code. We understand thai becoming a precatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege o: coins business with the City."
If the Disclos.ng Pany is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-"tS5fblofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
Page 7 of 13
i f the letters "NA.' the wore ''None.'' or no response appears on the lines above, it will be conclusively presumed '-ha: the Disclosing Party certified to the above statements.
D CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms thai are defined in Chapter 2-156 of tbe Municipal Code have the same meanings when used in this Part D.
- In accordance wiih Secuon 2-156-1 JO of the Municipal Code: Does any official or employer of the City have a financial interest in his. or her own name or in the name of any other person or entny in the Mailer"
i ^ Y'es No
NOTE If you checked "Yes" to Item D 1 proceed to Items D.2- and D.3. [f you checked "No" to Item D "... proceed to Par. E.
- Uniess sold pursuant lo z process of competitive bidding, or otherwise permitted, no City eiected 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 (il belongs lo the City, o: (ii) is sold for ra>,es or assessments, or iiii) is sold by virtue of legal process at the sun of the Cily I collectively. "Ciry Properly Sale") Compensation for property taken pursuant to the City's eminent domain power does noi constitute a financial interest u -thin the meaning of this Pan D
Does the Matter involve a C.i\ Property Sale?
[]\es 3 So
} If you checked es' -.o Hem D i provide :he names and business addresses of the Cm
officials or employees having such interesl and identify the nature of such interest-
Name Business Address Nature of Interest
£. The Disclosing Pirty further certifies tha: no prohibited financial interest in the Maner 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 10
Page 8 of 13
comply with ihese disclosure requirements may make any contract entered mm with the Cily in connection » it'n the Mailer voidable by the City.
x 1. T'nr D'.sciosir.e Party verifies tbat the Disclosing Party has searched any and all records of ths Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery i>r slaveholder insurance policies during trie slavery era (including insurance policies issued to slaveholder* that provided coverage for damage to or injury or death of their slaves 1. and rrcr Disclc-sin;: Party has found do such records
; T'nr Disclosmg Party verifies that, as a result of conducting tbe search in step 1 above, the
Disclosing Pary has found records of investments or profits from slavery or slaveholder insurance policies The Disclosing Pary 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:
N/A
SECTION VI -CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE- If th* Matter is federally funded, complete this Section VI If tbe Matter is not federally funded, proceed to Section VII. For purposes of this Section VI. rax credits allocated by the City and pro.-ee.-ls : ■* deb: obligations ofthe City are no: federal funding.
A. OEKTrriC iTION REGARDING LOBBYING
. Lis: helo« the names of all persons or entities registered under the federal Lobbying Disclosure Aci of I 9vf5 who have made lobbying contacts on behalf of ihe Disclosing Party wuS respect to the Matter- :*idd sheets if necessary!.
nTa
(If nn explanation appears or begins on tbe lines above, or if the letters "NA'' or if the word "None' appear. :: u-.ll be conclusively presumed that the Disclosing Pany means that NO persons or entities registered under the Lobbying Disclosure Aci o: 1995 have made lobbying contacts on behalf of the Disclosing Part> with respect to tbe Matter.)
2 Trie Disciosicg Parry has not spent and will not expend any federally appropriated funds to pay any person or entity listed ic Paragraph A.I. above for bis or her lobbying activities or lo pay any person or entiry to influence or attempt to influence an officer or employee of any agency, as defined b applicable federal law. a member of Congress, an officer or employee cf Congress, ot an employee of 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, -enew amend, or modify any federally funded contract, grant, loan, or cooperative agreement
Page 9 of 13
5. Th: Disclosing Parry will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects :be accuracy of the statements and information sci forth in paragraphs A.l and A 2. above.
£ The Disclosing Parry certifies tbat either', (il i' is not an organization described in section 50! ',c"il.41 of the Internal Revenue Code of 1986:or['ii) it is an organization described in sc-tion 505fc)i'4j ofthe Internal Revenue Code of 1986 but has not engaged and will noi engage ir. "Lobbying Activities"
5 If the Disclosing Parry is the Applicant, the Disciosmg Party must obtain certifications equal m form and substance to paragraphs A.l. through A 4. above from al. subcontractors before it awards any subcontract and the Disclosing Parry must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the Ciry upon request
B CERTIF.'C -\T!Ok. REG *>RDING EQU M EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require tbe Appiicant and all proposed subcontractors to submit the following information with their bids or in writing at the outsc; of negotiations. NOT FEDERALLY FUNDED
Is the Disclosing Pan> the Applicant'/'
flYf IjNo
If "Yes." answ er ihe three questions below
1 Have you developed and do you have or. file affirmative action programs pursuant to applicable
federal regulations!' l'See4l CFR Pan 60-2.1
I 1 Yes" [ ] No
2. Have you filed with the Join! Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or tbe Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ 1 Y« [ 1 No
5. Have you participated in aD>' previous contracts or subcontracts subtect to the equal opportunity clause"
I] Yes ' [jNo
If you checked "No" to question I. or 2. above, please provide an explanation: NOT FEDERALLY FUNDED
Page 10 of 13
SECTION VII - .ACKNOWLEDGMENTS. CONTRACT INCORPORATION. COMPLIANCE. PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
- Tnc certifications, disclosures, and acknowledgments contained in this EDS will become pan of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. Ciry assistance, or other City acion. and are material inducements to the City's execution of any contrac; or taking other action with respect to tbe Matter. The Disclosing Pany understands thai it musi 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 2-16-i- of the Municipal Code, impose ccnain duties and obligations oo persons or entities seeking City contracts, work, business, or transactions. Tbe full text of these ordinances and a training program is available on lire at w-ww .ciivofchicaco.ort:'Ethics, and may also be obtained from the City's Board of Ethics. rA0 N
Sedgwick Si Suite 5D0 Chicago. IL 60610. (312) *44-OPPo. The Disclosing Parry roust comply fully with tht applicable ordinances.
- If the City determines Thai any information provided in 1h:s EDS is false, incomplete oi inaccurate, any contract or other agreement in connection with whicr. it is submitted mBy be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if noi rescinded or void), ai law. or :n equitv. 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 ia» for a false staicraem of material facl may include incarceration and an award to the City of treble damages.
- It is the City s policy lo make this document available lo tbe 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 Interact, m response to a Freedom of Information Acl 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 c ontained ir. this EDS and also authorizes the Ciry 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, tbe Disclosing Party must supplement this EDS up to tbe 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 musi update this EDS as the contract requires. NOTE: With respect to Matter? subject to Aniclc 1 of Chapter 1-22 of the Municipal Code (imposing PERMANENT INELIGIBILITY for cenain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter I -23 and Section 2-1 54-020 of tbe Municipal Code.
The Disclosing Party represents BDd wanants that:
Page 11 of 13
T I. The Disclosing Pany is not delinquent in the payment of any tax administered by the Illinois Department o.' Revenue nor are the Disclosing Pany or its Affiliated Entities delinquent in paying any fine, fee. tax or other charge owed to the Cits'. This includes, but is noi 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 wili no; 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 Disciosing Party if the Appiicant. the Disclosing Party will obtain from any contraciors'subconrractors hired or to be hired in connection with the Matter certifications equal in form and substance 10 those m F. ]. and F.2. above and will noi, without the prior written consent of the Ciry, use any such contractor'subcontractor thai does not provide such certifications or that the Disclosing Party has >-eason to believe has not provided or cannot provide truthful certifications.
NOTE: I'" the Disclosing Party cannot certify as to any of the items in F. I., F.2. or F.3. above, tr. explanalor* statement must be attached to this EDS.
CERTIFICATION
Under pent);) of penury. the person signing below: (I) warrants that he/she is authorized lo execute this EDS and Appendix A fif applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications arid siaiements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
-DC Estate, LLC
Randall danger fPrint or type name of person signing)
Manager (Prim or type title of person signing)
Signed and su orn to before me on (date) 1 * °) 0 ~ I ^)
« f c-C )'< County. T\it nit; S fstate).
Notarv Public.
Commission empires 7 ~\ S> ~ \ S
Page 12 of 13
OFFICIAL SEAL ELIZABETH VY1$S WJWHY PUBIC STATE OF UMOB
tttcaumtKHBSfegnamm
CITY OF CHICAGO ECONOMJC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A
FAMILIAL RELATIONSHIPS WTTH ELECTED CITY OFFICIALS AND DEPARTMXNT HEADS
This Appendiv is to br completed only b> (a) tbe .Applicant, and Cb) 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 musi disclose whether such Disclosing Parry or any "Applicable Party" or an> Spouse or Domestic Partner thereof currently has a "familial relationship" witr any elected city official or department head. A "familial relationship1' exists if. as of tbe date this EDS ts signed, the Disclosing Party or any "Applicable Party' or any Spouse or Domestic Parma thereof is related to the mayor, am alderman, the city clerk, tbe 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. daughtcr-in-iaw stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister
'Applicable Party'" mean* (1) all executive officers of the Disclosing Party listed in Section II .3.1 .a. if the Disclosing Parry if a corporation; all partners ofthe Disclosing Party, if the Disclosing Parry is a general partnership- all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a 'limited partnership- all managers, managing members and members of the Disclosing Party, if the Disclosing Parry :« e limited liability company: (2) all principal officers of the Disclosing Party, and (?) nay person having more than a 7.5 perceni ownership interest tn the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director chief fioaacial officer, treasurer or secretary of a legal entity or any person exercising gimila- authority.
Docs the Disclosing Parry or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a.''fam<!ial relationship" with an elected city official oc department head?
| JYes |x]No
If yes. please i dcntify below (I) the name and title of such person, (2) the name of the legal entity to which such person is connected: (5) the name and title of the elected ciry official or department head lo whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal nam: of she Disclosing Pany submitting this EDS. Include d/b/a/ if applicable:
EA Langer &_ Associates, LLC
Cbeck ONE of the following three boxer:
Indicate whether the Disclosing Party submitting this EDS is:
1 the Applicant Two property owners. We are one of them. OR
2. [ ] a legal entity holding a direct or indirect interest in tbe Applicant State the legal nemc of the
Applicant in which the Disclosing Party holds an interest:
OR
1. (j i 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:
B. Business address of the Disclosing Pany: 3 7&7 /T) Rai-.^i Q»<
CVirti^B , tSA InQU >3
C Telephone. (77^) Itf-tUP Fax: Qt?j\ Ltt-*6TI Email: L-^yfgi M PiUny
- Name of contact person. ^KorsA&ll l-l ■ Lt,t.g<-y
- Federal Employer Identification No. (if you have one!:
F Brief description of contract, transaction or other undertaking (referred to below as tbe "Matter") to which this EDS penains. (Include project number and location of property, if applicable);
Re-subsubdivision to reduce the number of lots and property index
numbers tor convenience ot the municipality and parties-
G. Which Ciry agency or department is requesting this EDS? .
If the Matter is a contract being handled by tbe City's Department of Procurement Services, please complete the following.
Spec ificau'on # and Contract *f
V«r. 01-01-11
Page 1 of 13
SECTION 11 - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE Or THE DISCLOSING PARTY
I Indicate the nature of tbe Disclosing Party:
[ j Person p$ Limited liability company
i} Publicly registered business corporation [] Limited liability partoersbip'
[ j Privately held business corporation | ) Joint venture
[ ] Sole proprietorship [ ] Not-for-profit corporation
[] General partnership (1% the not-for-profit corporation also a 501(c)(3))?
[) Limited partnership [ ] Yes [ ] No
( j Trust { ] Other (please specify)
2 For legal entities, the state (or foreign country) of incorporation or organization, if applicable: Illinois
3. For legti entities not organized in the State of Illinois: Has tbe organization registered lc do business in the State of Illinois as a foreign entity?
r. jYes [)No []K:A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. Lisi pelow 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 arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal titlerioldcT(s).
If ihe entity is a general partnership, limited partnership, limited liability company, limited liability partnership or join1, 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 ofthe Disclosing Party. NOTE: Each iega! entity listed below must submit an EDS on its own behalf.
Name Title
Randall Langer 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 tbe Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joinl 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
D'^'^sing Party
None *
SECTION III BUSINESS RELATIONSHIPS WITH C1TV ELECTED OFFICIALS
Has the Disclosing Pany had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in tbe 12 months before tbe date this EDS is signed?
If yes. please identify below the name(s) of such Ciry elected official(s) and describe such rclationshipts'i.
SECTION JV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Parry must disciose 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 ir. connection with the Matter, as well as the nature ofthe relationship, and the total amount of the fees paid or estimated to be paid. Th; Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist'' means any person t>r entity who undertakes to 'influence any legislative or administrative action on behalf of any person or entity other than. (11 a not-for-profit entity, on an unpaid basis, or (2; himself. "Lobbyist'" also means any person or entity any pan of whose duties ss an employee of another include; 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 Ciry 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 rie retained) lobbyist, etc.) "hourly rate" or 'l.b.d." is
not an acceptable response.
None
(Add sheets if necessary j
P5 Check here if the Disclosing Parry has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415. substantial owners of business entities tha: contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly o: indirectly owns 10% or more of the Disclosing Parry been declared in arrearage on any chiic suppon obligations by any Illinois coun of competent jurisdiction?
| ] > es j3} ^o f j No person directly or indirectly owns J0*/b or more ofthe
Disclosing Parry.
If "Yes.'' has the person entered iclo a coun-approved agreement for payment of all support owed and is the person in compliance with tha: agreement?
(' J Ves [ ] Nc
B. FURTHER CERTIFICATIONS
1 Pursuant to Municipal Code Chapter 1-23. Article 1 ("Article l")(which the Applicant sbouid 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 certinsF as follows: neither the Applicant nor any controlling person is currently indicted or chargec with, or has admitted guilt of, or has ever been convicted of, or placed under supervision foT. any criminal offense involving actual, attempted, or conspiracy lo commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the Ciry or any sister agency, and (ii) tbe Applicant understands and acknowledges tbat compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, tbe 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 Parry is a legal entity, all of those persons oi entities identified in Section II.B.I. of this EDS:
a 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:
b have noi. within t five-year period preceding the date of this EDS. been convicted of e crimina. offense, adjudged guilty, or had a civil judgment rendered agains: 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 properry:
- are no: presently indicted for, or criminally or civilly charged by, a governmenttl emity (federa. stnie or local'i with committing any of the offenses se: forth in clause B.2.b. of this Section V.
- hav; not. within a five-year period preceding the date of this EDS. bad one or more public transaction* (federal, state or local) terminated fol 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 crimina) or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unii of local government.
- The certifications, in subparts 3. < and 5 concern:
- any Contractor'' (meaning any contractor or subcontractor used by the Disclosing Parry in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV. "Disclosure of Subcontractors and Otbtrr Retained Parties'").
- any "Affiliated bntiry" (meaning a person or entity that, direcdy or indirectly: controls tbe Disclosing Party, is controlled by the Disclosing Pany. or is. with the Disclosing Party, under common control of another persor. or entity. Indicia of control include, without limitation, interlocking management ot 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 e business entity to do business with federal ot 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 thai directly or indirectly controls the Contractor, is controlled by it, or. with the Contractor, is under common control of another person or entity;
- any responsible official of the Disclosing Party, any Connractot ot any Affiliated Entity or any other official, ageni 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, an) Contractor or any Affiliated Ennty (collectively "Agents").
Page 5 of 13
Neither the Disclosing Part), nor any Contractor, nor an> Affiliated Entity of cither the Disclosing Parry or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or. with respect it. a Contractor, an Affiliated Entity, or an Afftiiaied Entity of a Contractor during the five years before the date tiT such Contractor's or Affiliated Entity's contraci or engagement in connection w:th 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 employees official capacity.
- agreed or colluded wirh 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 re strain I of freedom of competition by agreement 10 bic a fixed price or otherwise: or
c made tr. idrr.tssinr of such conduct described In a or b above tbat is a matte: of record, bu: heve no: been prosecuted for such conduct: or
d violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance)
i Neither the Disclosing Party. Affiliated Emily or Contractor, or any of their employees, officials, agents or partners, is bBrred from contracting with any unit of state or local government as a result of engaging in or being convicted of 11) bid-rigging in violation of 720 ILCS 5/33E-3: (2> bid-rotating :r. violation of 720 ILCS 5 3.-.E-11: ot (21 any similar offense of any state or ofthe United Stalet of America that contains the same elements as the offense of bid-riggvog ot bid-rotating.
- Neither the Disclosing Party noi any Affiliated Entity is listed on any of the following list; maintained by the Office of Foreign Assets Control of the U.S Department ofthe Treasury or ihe Bureau of Industry and Security of tbe U.S. Department of Commerce or their successors' the Specially Designaied Nationals List, tbe Denied Persons List, the Unverified List, the Entity List and tbe Debarred Lisi
- 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 Pany is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
Page 6 of 13
If the letters ''NA." the wore "None." or no response appears on the lines above, it will be conclusively presumed tha: the Disclosing Parr, certified to the above statements.
R. Tu the best ofthe 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-
raunth period preceding tbe execution date of this EDS. an employee, or elected or appointed official.
o: the Cit\ ofChicaeo (if none, indicate with "N 'A' or 'none"). N/A
9 To the best ofthe Disclosing Parry's knowledge after reasonable inquiry1, 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 tb:s EDS. to an employee, or eiected or appointed official, of the City of Chicago For purposes of this statement, a "gift" does not include: (il anything mad: rer.-rt!!\ available ic Ciry employees or to the general public, or (ii) food oi drink provided in th; course of official Ciry business anc having a retail value of less thar. S20 per recipient ii:" none, indicate with "N A" or "none"!. As 10 any cr-f*. listed below . please also list tbe name ofthe City recipient
jrrjr-
C CERTIFICATION OK STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies tha; the Disclosing Party i.eheck onc'i
[ ] i* ?Cj is noi
a "financial institution" as defined in Section 2-32-*55(bi of the Municipal Code
2 If tht- Disclosing Party IS a financial institution, then the Disclosing Party pledges'
"Wc are not anc will noi become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We furtber pledge that none of our affiliates is, and none of them will become, a predatory lender as defined :g Chapter 2-32 of the Municipal Code. We understand thai becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of come business with Ac City."
If the Discios.ng Pany is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-4S5(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary)
Page 7 of 13
If ihe letters in; wore ■'None.' or no response appear* on the lines above, ii will be
conclusively presumed tha: the Disclosing Parry certified to rhe above statements.
D CERTIFICATION' REG ARDIN'G INTEREST IN CITY BUSINESS
Any words or terms that are defined tn Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
i In accordance wilt Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her owr. name or in tbe name of any other person or entity in the Matter"
1 !■ Yes l5:*0
NOTE' If you checked "Yes' to Item D I . proceed to Items D.2. and D.3. If you checked "No" to Item D.l proceed to Par. E
2. Uniess sold pursuant to t process of competitive bidding, or otherwise permitted, no Ciry elected official or employee shall have a financial interest in his or her own name or in the name of any other person or cnti-y :n the purchase of any property that (il belongs lo ihe City, or (ii) is sold for taxes or assessments, or ( iii) ij soid by virtue of iegai process a! the suit of tbe City (collectively "City Properrv Sale'") Compensation for property taken pursuant co the City's eminent domain powe: does noi conmiuir a financial interest within the meaning of this Part D.
Docs rbc Matter involve i. C ti Property Saic?
I J Yes Nc
2 If you checked "> eV' -,o Item D i provide the names and business addresses ofthe City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature oflntercs!
t The Disclosing Party further certifies that no prohibited financial interest in the Matter will , be acquired by any Ciry official or employee
E CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither 1. or 2 below If the Disclosing Party checks 2., tie Disclosing Parry must disclose beiow or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13
comply u ;ih these disclosure requirements may make any contract entered into with the City in connection » i:h iht Metier voidable by the City
x 1 T'nr D-.sciosir.c Tarry verifies tha' the Disclosing Parry has searched any and all records of the Disclosing Party aod 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 thai provided coverage for damage to or injury or death of their sIbvbsi. and tn; Disclot-.nc Part; has found co such records
Z T'nr Disclosing Parry verifies that, as a result of conducting tbe search in step 1 above, tne
Disclosing Par\ has found records of investments or profits from slavery or slaveholder insurance policies The Disclosing Pany verifies thai the following constitutes full disclosure of all such records, including the names of any and 2tl slaves or slaveholders described in those records'
N/A
SECTION NT - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE If tht Matter is federally funded, complete this Section VI If tbe Matter is not federally funded, proccec '.c Section VII. Fo-purposes of this Section VI. rax credits allocated bj the City and proceeds : r deb', oolicanons of rhe City are no- federal funding
A CERTTF IC ATION RH CARDING LOBBYING
. Lis: hdou :h; names of all persons or entities registered under the federal Lobpying Disclosure Act cf I''0? who have made lobbying contacts on behalf ofthe Disclosing Party wiia ,-espcct to the Matter .Add sheets if necessary!.
nTa
(If no explanation appears or begins on tbe lines above, o: if the letters "NA* or if the word "None' appear. :: will br conclusively presumed that tne Disclosing. Pany means tha: NO persons or entities registered under tne Lobbying Disclosure Ac; o: 1995 have made lobbying contacts on behalf of the Disclosing Pa-n " i:h respect to the Matter.'
1 The Disclosing Parry nas 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 pa\ any person or entity to influence or attempt to influence an officer or employee of any agency. as defined b applicable federal lau. a member of Congress, an officer or employee of Congress, o: an employee of member of Congress, in connecnon with the award of any federally funded contract, makinc an? federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, -enew. amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
J. Tht Disclosing Parry will submit an updated certification at the end of each calendar quarter in « hich there occurs any even: that materially affects the accuracy of thj statements and information set form in paragraphs A 1 and A.2. above.
- The Disclosing Party certifies that either: li) it is not an organization described in section 5P!'cH4> <>f the Internal Revenue Code of i 986: or Hit it is an organization described in section 50! i'cli*j of the Internal Revenue Code of 1986 but has not engaged and will cot engage ir. "Lobby:rg Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal m form and substance to paragraphs A.I through A.4. above from all subcontractors before it awards ar.v subcontract and the Disclosing Parry must maintain all such subcontractors' certifications for ;bc duration ofthe Matter and must make such certifications promptly available to the City upon request.
B CERTIFIC *.T!0\ PEG \RDING EQUAL EMPLOYMENT OPPORTUNITY
If the Martc; is icdcraliy funded, iedcrai regulations require tbe Applicant and all proposec subcontractors to submit the following information with their bids or in writing at the outset of negotiations. NOT FEDERALLY FUND2D
Is the Dlsclosmi: Party the Applicant'1
HYc- j]No
If "Yes." answer tht three questions below
i. Have you developed and do you have or. file affirmative action programs pursuant to applicable federal regulations? f5.ee 41 CFR Pan 60-2 !> i)Yes [JNo
2 Have you filed with the Joint Reporting Committee, the Diiectoi ofthe Office of Federal Coniraci Compliance Programs, or tht Equal Employment Opportunity Commission Mi reports due under the applicable filing requirements''
11 Yet [lNo
1>. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
{ ] Yes [] No
If you checked '"No" to question 1. or 2. above, please provide an explanation: NOT FEDERALLY FUNDED
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 ic connection with the Matter, whether procurement. City assistance, or other City action, aod arc materia) inducements to the City's execution of any contract or taking otber action with respect to the Matter The Disclosing Party understands that tt must compiy with a!) statutes, ordinances, and regulations on which this EDS is based.
- The City's Govemmenta: Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impost certain duties and obligations on persons oi entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www cirvofchicago.orE'Etbics. and may also be obtained from the City's Board of Ethics. '40 N-
Sedgtt ick St Suite 51>t>. Chicago. IL 60610. (312) 744-9660. The Disclosing Party must comply fuliy with the applicable ordinances.
- If the City Determines thai any information providcc in this EDS is false, incomplete or inaccurate, any contract or other agreement m connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies UDder tbe contract oragTcemenl (if not rescinded or void), at lav or ;n equity, including terminating the Disclosing Pany's participation in the Matter and/or declining to allow the Disclosing Parry to participate in other transactions with the City. Remedies a: lau for a false statement of material fact may include incarceration and an award to the Ciry of treble damages.
D It is the City's po'uc\ to make this document available to tbe 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 Aci 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 ir. t'ms EDS and also authorizes the Ciry to verify tht accuracy of any information submitted in this EDS
E. The information provided in this EDS must be kept cunent. In the event of changes, the Disclosing Party must supplement this EDS up to the time tbe City tBkes action on the Matter. If the Matter is a contract beinc handled by the City's Department of Procurement Sen-ices, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter I -23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and wanants that".
Page 1 1 of 13
F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department o* Revenue, nor are the Disclosing Pany or its Affiliated Entities delinquent in paying an> fine, fee. tax or other charge owed to the Ciry. This includes, bui 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 no: use. nor permit their subcontractors to use, any facility listed by the U.S. E.P-.A. on the federal Excluded Panics List System ("EPLS") maintained by "he U. S. General Services Administration.
F.3 If the Disclosing Pany is the Appiicant. 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.). aDd F.2. above and will not, without che prior wntten consent of the City, use any such contraetor'subcontractor that does not provide such certifications or that the Disclosing Pany has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If'.he Disclosing Party cannot certify as to any ofthe items in F.!., F2- or F.2. above, ar. explanatory statement must be attached to this EDS.
CERTIFICATION
Under pcntl;> or penury, the person signing below: (1) warrants that he/she is authorized lo 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 compicie as of the date furnished to the City.
iSign herei
Randall Langer ("Print or type name of person signing)
Manager (Print or type title of person signing)
at ( cC.i<
County. ~At\\ \ nc ; % (state).
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT .AND AFFIDAVIT APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
Tbis Appendix is to be completed only by (a) the Applicant, and (b> any legal entity which has s 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.
Unocr Municipal Code Section 2-154-015. the Disclosing Parry must disclose whether such Disclosing Parry or any "Applicable Parry" ot any Spouse or Domestic Partner thereof currently has a 'familial relationship" with any elected city offieiai or department head. A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party' or any Spouse or Domestic Partner thereof is related ic the mayor, any alderman, the city clerk, the aty 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, f8thcr-in-law, morher-in-law, son-in-law, daughrcr-in-iaw . stepfather or stepmother stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
''Applicable Parrv'" means 11 > all executive officers of the Disclosing Party listed in Section H.SJ.a if tht Disclosing Pary is. a <X)rporaiion; all partners of the Disclosing Party, if the Disclosing Parry is a general partnership all general partners and limited partners ofthe Disclosing Party, if the Disclosing Parry is a limited partnership: all managers, managing members and members ofthe Disclosing. Pany, if the Disclosing Party u t limited liability company: (2) all principal officers ofthe Disclosing Party, and (3) any person having more than a 7.5 percent ownerehip interest in the Disclosing Party. "Principal officers" means tbe president, chief operating officer, executive director, chief financial officer, treasurer or secretary of b legal entity or any person exercising similar authority
Docs the Disclosing Parry or any "'Applicable Party"' or any Spouse or Domestic Partner thereof currently have a."fanii'.ial relationship" with an elected city official or department head?
[ ] 1 cc (xJ No
If yes. please identify below (n the name and title of such person. (2) the name of the legal entity to which such person is connected: Q.) the name and title ofthe elected city official or department bead to whom sucp. person has a familial relationship, and the precise nature of such familial relationship.
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 - GENERAL INFORMATION
A. Legal nam; of the Disclosing Parry submitting this EDS. Include d/b/a/ if applicable: HAL Series Acquisition, LLC Skyway
Check ONE of the following tbree boxes:
Indicaie whether the Disclosing Party submitting this EDS is:
!. [xj tbe Appbcant Two property owners. We are one of them. OR
2 [ } a legal entity holding a direct oi indirect interest in the Applicant State the legal name of the
Applicant in which ".he Disclosing Parry holds an interest:
OR
3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Pany holds a right of control:
B Business address of the Disclosing Pany 3 7& 7 /T) ^ar.Mi Q«x
C Telephone (?^) <iZ<7-ll.l-0 Fax■ (77& LCt-SOTI Email: Lmgrz-gi M fiU~yr
D. Name of contact person. ^Kor>Aftll H U&.^r^
E Fcoeral Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (refencd to below as tbe "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Re-substibdivision to reduce the number of lots and property index numbers tor convenience ot the municipality and parties.
G. Which Ciry agenty or department is requesting this EDS?
If the Matter is a contract being handled by tbe City's Department of Procurement Services, please complete the following:
Specification £ and Contract U
Ver. 01-01-12
Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY'
I Indicate the nature of the Disclosing Party:
[ } Person [3\ Limited liability company
f ; Publicly registered business corporation [ ] Limited liability partnership
[ j Privately held business corporation [ J Joint venture
[ ] Sole proprietorship [ ] Not-for-profit corporation
| ] General partnership (H tbe not-for-profit corporation also a SOlfc)^))*1
j ] Limited partnership [ ] Yes [ ] No
I j Trus: [ ) Other (please specify)
2 For legal entities the state (or foreign country') of incorporation or organization, if applicable: Illinois
?. For legal entities no: organized in the State cf Illinois: Has tbe organization registered it; do business in the State of Illinois as a foreign entity''
; ; Yes []No [IN'A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. Lisi beiew the full names and ntles of all executive officers and all directors of the entity. NOTE: For noi-for-profu 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 titleholdcr(s').
If ihe entity is z general partnership., limited partnership, limited liabiliry company, limited liability pannership or join: venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal enntv listed below must submit an EDS on its own behalf.
Name Title
H A Langer it Associates LLC Manager
2. Please provide tbe following information concerning eacb 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 iD a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
_ Disclosing Party
DC ESTATE, LLC 376?/0.R-rm A* 10°*
SECTION III - BCSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Pany had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any Ciry elected official in the 12 months before the date this EDS is signed?
[ ) Yes p? No
If yes. please identify br'tow the name(s) of such City elected official(s) and describe such relationship! s>'
SECTION |\ - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, acrountant. consultant and any other person or entity whom the Disclosing Party has retained or expects to main in connection with the Matter, as well as the nature of the relationship, and the totel amount of the fees paid or estimated to be paid. The Disclosing Parry is not required to disclose employees who are paid solely through the Disclosing Pany's regular payroll.
"Lobbyist'' means any person oi entity who undertakes, to influence any legislative or adtnmisn&nve action on behalf of any person or entity other than: (I) a not-for-profit entity, on an unpaid basis, or (2 ;■ himself. "Lobbyist'' also means any persoD or entity any pan of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If tbe 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 Pany Fees (indicate whether
retained or anticipated Address (subcontractor, attorney. paid or estimated.) NOTE:
to ?e retamud I lobbyist, etc.) "hourly rate" or 'Vo.d." is
not an acceptable response.
None
(Add sheets if necessary i
[>3 Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-41 « substantial owners of business entities that contract with the City roust remain in compliance with their child suppon obligations throughout tbe contract's term.
Has any person who directly or indirectly owns !0°/i> or more of tbe Disclosing Party been declared in anearage on any chiic suppon obligations by any Illinois court of competent jurisdiction?
| ) Yes ['j No f ] No person directly or indirectly owns 10"'i or more of the
Disclosing Party.
If "Yes." has the person entered into a conn-approved agreement for payment of all support owed and is the person in compliance with that agreement?
i P s* I J
B FURTHER CERTIFICATIONS
I Pursuant to M unicipai Code Chapter 1 -23. Article I ("Article In)(whtcb the Applicant should consult for defined terms (e.g "doing business"! and legal requirements'!, if the Disclosing Party submitting this EDS is (he Applicant and is doing business with tbe Ciry. then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is cunently 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 tbat 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 Id Aniclc I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
- The Disclosing Party and. if tfie Disclosing Parry is a legal entity, all of those persons o: entities identified in Section II.B.) of this EDS:
z. arc not presently debarred, suspended, proposed for debarment, declared ineligible or volumariK excluded from any transactions by any federal, state or local unit of government
b have not. within z five-year penot! preceding tbe date of this EDS. been convicted of a crirmna 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 ot state antitrust statutes; fraud, embezzlement, theft, forgery, bribers-: falsification or destruction of records; making false statements: or receiving stolen properry:
c. aTe no", presently indicted foT. or criminally or civilly charged by. a governmental entity ifedera state or local'i with committing any of the offenses set forth in clause B.l.b of this Section V.
d hsve not. within a five-year period preceding the date of this EDS. had one or more public transactions ifederal, state or local) terminated for cause or default and
e. have not. within a five-year period preceding the dale of this EDS., been convicted, adjudged guilty, or found liable m a ctvf. proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any stale, or any other unii of local government
- The ce-tificatiop^ in subparts 3. 4 and 5 concern.
ihe Disclosing Par:y
■ any "Contractor"' fmeaning 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, direedy or indirectly controls the Disclosing Party. is controlled by the Disclosing Party, or is. with the Disclosing Party, under common control of another pcrsor. or entity. Indicia of control include, w'nhout 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 ineligibilitv of a business entity to do business with federal or state or local government, including tbe City, using substantially the same management, ownership, or principals as tbe ineligible entity)-with respect to Contractors, tbe term Affiliated Entity means a person or entity tbat direedy 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 tbe 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 Part), nor any Contractor, noi any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during Ihe five years before the date this EDS is signed, or. with respec; to s Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the f:»e yetrs before the dale of such Contractor's or Affiliated Entity's contract or engagement in connectioc wiih tbe Matter:
a bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting ro bribe, a public officer or employee of tbe City, the State of Illinois, or any agency of tbe federal government or of any state or local government in the United States of America, in that officer's or employee s official capacity:
b agreed or colluded with other bidders or prospective bidders, or been a party lo any such
agreement, or been convicted ot adjudged guilty of agreement or collusion among bidders ot prospective bidders, in restraint of freedom of competition b\ agreement to bid a fixed price or otherwise, or
c made zv. admission of such Conduct described in e. or b. above thai is a matter of record, but have no: been prosecuted for such conduct: or
d violated the provisions of Municipal Code Section 2-92-6)0 (Living Wage Ordinancei.
i Neither the Disclosing Party. Affiliated Entity or Contractor, or any of their employees, officials, agents or partners is banco from contracting with any unn of state or local government as a result of engaging in or beinc con\ icted oft II bid-ngging in violation of ?20 ILCS 5/33E-2: (2i bic-rotatine :r. violation of "20 fLCS 5 33E-". or (3i any similar offense of any state or of the United Stute; o: America that contains the same elements as the offense of bid-rigging or bid-rotating
- Neither trie Disclosing Pany nor any Affiliated Entity is listed on any of tbe following Itsli maintained b\ the Office of Foroign Assets Connol of the U.S Depanmeni of tht 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 tbe Debarred List.
- The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector Cenerall. 2-56 (Inspector General) and 2-156 (Governmental Ethics» of ihe Municipal Code.
"\ If the Disclosing Party is unable to certify to any of the above statements in this Pan B (Further Certifications), tbe Disclosing Pany must explain below:
_
Page 6 of 13
If th: letters 'NA.' the word "None." or no response appears on the lines above, il will be conclusively presumed tha: :hr Disclosing Parry certified to the above statements.
f>. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete iist of all current employees of the Disclosing Party who were, at any time during the 12-
raontb period preceding the execution date of this EDS. an employee, or elected or appointed official.
at the Cit\ ofChkaeo (if none, indicate with "N.'.V or -none") N/A
9 To tbe best ofthe Disclosing Party's knowledge after reasonable inquiry, the following ss a complete lis: 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 Ciry of Chicago. For purposes of this statement, a "gift" does not induce: (0 anything rnudr generally available ic City employees or to the genera! public, or (ii) food or drink provided in the course of official Ci;y business and having a retail value of less than S20 per recipient (if none, indicate with '"N A"' ot- "none"I. As 10 an> gin "listed below please also list the name of the Clt> recipient
rrnr
C CERTIFICATION OK ST ATI'S AS FINANCIAL INSTITUTION
- The Disclosing Part\ certifies tha: the Disclosing Parry tcheck one*
[ ] is Soj not
z "financial institution" as defined in Section 2-?2-455(bi of the Municipal Code
- If thf Disclosing Party IS a financial institution, then the Disclosing PBny pledges.
"We are noi and w ill not become a oredatory 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 prcdaton lender a» defined is Chapter 2-32 of the Municipal Code. We understand that becoming a precatory lender or becoming an affiliate of a predatory lender may result id the loss o: the privilege of doing business with die City.'
If tbe Discios.ng Parry is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-4SSfb) ofthe 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
': f the lencrs "N A." the. wore ' None.'' or no response appears on tbe lines above, it will be coneius:ve!> presumed :ha: '.be Disclosing Parry certified to tbe above statements
D CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same meanings when used in this Part D
i !n accordance with Section 2-156-1 10 of the Municipal Code: Does any official or employer of the Ciry have a financial interest in his or her owr. name or in the name of any other person or entity in the Matter"
l". Yes [XNo
NOTE' li* you checked "Yes' to Item D.l . proceed to Items D. 2. and D. 3. If you checked "No" to Item D. i proceed to Pan E
2. U;mess sold pursuant to a process of competitive bidding, or otherwise permitted, no Ciry 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 :n the purchase of any property thai ii) belongs to the City, ot f il l is sold for taxes or assessments, or f iiil is soid by virtue of legal process at the suit of the City Icollec.ively "City Property Sale"). Compensation for propeny taken pursuant to the City's eminent domain power does noi constitute a rinanciai interest wuhin the meaning of this Pan D.
Does the Matter im o!v- a Citv Propeny Sale"
1 ] Y es N e
T- If yen checked "'i es' ;o Item D.l provioe the names md business addresses of tht Citi officials or employees having such interest and identify the nature of such interest:
Name 3usmess Address Nature of Interest
£. The Disclosing Party further certifies that noprohibited financial interest in the Matterwill be acquired by any City official or employee.
E CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither I. or 2. below If tbe Disclosing Party checks 2., the Disclosing Party must disclose beiow or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13
comply w tlh these disclosure requirements may make any contract entered into with the City in. connectior with the Matter voidable by the Ciry.
1. The O'.sclosir.c Pans \-erifies tha: the Disclosing Party has searched any and al! records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits Crox slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholder* that provided coverage for damage to or injury or death of their slas-es). and t'nr Discios:-;: Pirry has found no sucn records
2 Tne Disclosing Pany venfiss that, as a result of conducting tbe search in step I above, the
Disclosing Party has found records of ir.vestmenrs or profits from slavery or slaveholder insurance polities The Disclosing Parry verifies that the following constitutes full disclosure of ali such records, including the names of any and all slaves or slaveholders described in those records:
N/A
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE If the M aner is fi-durally funded, complete this Section vi If tbe Matter n not federally funded, proceec /■ Sectior. VII. For purposes of this Section VI, tax credits allocated bs the City and proreec1 : :" der>: <>plications of the City are no: federal funding.
A CERTIFICATION REGARDING LOBBYING
Lis: betou the names of all persons or emmcs registered under tne federal Lobbying Disclosure Act of loi>5 u'no have made lobbying contacts on behalf of the Disclosing Pany »'i6 respect t< tne Matter- 'Add snceis if necessary).
nTa
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None' appear. :: w.ll be conclusively presumed that the Disclosing Pans means that NO persons or entities registered unaer the Lobbying Disclosure Ac; of 199? nave, made lobbying contacts on behalf of the Disclosirc Pan\ u'lti respect to the Matter.i
2 Tne Disclosing Party has not spent and will not expend any federally appropnaied funds in pay any person or entity listed in Paragraph A I. above for bis or ber lobbying activities or to pay any person o- entity to influence or attempt to influence an officer or employee of any 2geney. as defined b applicable federal law. a member of Congress, an officer ot employee of Congress, or an employee of member of Congress, in connection with the award of any federally funded contract, maktnc acs federally funded gram or loan, entering into any cooperative agreement, or to extend, continue, renew amend, or modify any federally funded contract, grant, loan, or cooperative igreemeni.
Page 9 of 13
3. Tht Disclosing Party will submit an updated certification at the end of each calendar ouaner in which, then octtun any even; that materially affects the accuracy of the statements and information set forth m paragraphs A.l. and A.2. above.
- The Disclosing Party certifies that either, (il it is not an organization described in section 50! 'e ii.41 of the Internal ft evenue Code of 1986. or Oil it is an organization described in section 50'. i cli'41 of the Internal Revenue Code of 1986 but has not engaged and will cot engage ir. " oobbyir.y Activities"
5 If the Disclosing Parry is the Applicant, the Disclosing Parry must obtain certifications equal in form and substance to paragraphs A.l. through A.-4. above from all subcontractors before n awards any subcontract and the Disclosing Parry must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to tht City upon request.
B CERTlFlt" ».T!ON REG \RD!NG EQU AL EMPLOYMENT OPPORTUNITY
If tht 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 NOT FEDERALLY FUNDED
Is the Disclosing Part> the Applicant?
[*jYe= |']No
If "Yes." answer r.he three questions below
- Have you developed and do you have on file affirmative action programs pursuant to appiicabl; federal regulations? (See 41 CFR Pan 60-2.'.
I] Yes [JNO
- Have you filed with ihe .loini Reporting Committee, tht Director of tbe Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission ali repons due under tht applicable filing requirements?
tiYes (INo
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[]Yes []No
If you checked "No" lo question I. or 2. above, please provide an explanation:
NOT FEDERALLY FUNDED
Page 10 of 13
SECTION VII- ACKNOWLEDGMENTS. CONTRACT INCORPORATION. COMPLIANCE. PENALTIES, DISCLOSURE
Tbe Disclosing Party understands and agrees that:
A The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and tbe City- in connection with the Matter, whether procurement. City assistance, or other Ciry action, and arc material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Pany understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
B. The City's Governmental Ethic* and Campaign Financing Ordinances. Chapters 2-156 and 2-16£ of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business., or transactions. Tbe full text of these ordinances and a training program is available on line al www.citvofchicago.ortt'Ethics. and may also be obtained from the City's Board of Ethics T40 N
Sedgwick Sl. Suite 500. Chicago. IL 60610. (312) 744-9660. Tne Disclosing Party must comply fuli\ with tiit applicable ordinances.
C If the C ity determines thai any information providec in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which r. is submittec may be rescinded or be void or voidable and the City may pursue any remedies under the contract or agreement (if no: rescinded or void I ai law or in equiry. including terminating the Disclosing Partv's participation in the Matter and/or declining to allow the Disclosing Party to participate tr. other transactions u ith the City. Remedies a: iaw for a false statement of materia! fact may include incarceration and an award to the City of treble damages.
D. It is the City» po'no 10 roai,e this document available to tbe puoiic on its Internet site and'or upon request Some or all ofthe information provided on this EDS and any attachments to this EDS rosy be made available to the public on the Internet, in response to a Freedom of Information Aci request, or otherwise. By completing anc 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 ir. 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 cunent In the event of changes, tbe Disclosing Party raus: supplement this EDS up to tbe time tbe City takes action on the Matter. If tbe Matter is a contract being handled by the City's Department of Procurement Sen-ices, the Disclosing Pany must update this EDS as the contract requires. .NOTE: With respect to Matters subject to Aniclc I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for cenain specified offenses), the information provided herein regarding eligibility must be kepi currem for a longer period, as required by ChapteT I -23 and Section 2-1 54-020 of the Municipal Code
The Disclosing Pany represents arid wanants that:
Page 11 of 13
F.l. The Disclosing Parry is noi delinquent m the payment of any tax administered by the Illinois Departmen!. of Revenue, nor are the Disclosing Pany or its Affiliated Entities delinquent in paving an) fine. fee. tax or other charge owed to tht City. This includes, but is not limited to, all water charge-., sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 ll the Disclosing Pany is the Appiicant. the Disclosing Pany aDd its Affiliated Entities wili not use. nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Panies List System ("EPLS") maintained by the U S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Parry will obtain from any contraciors'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 thai does not provide such certifications or that the Disclosing Pany 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 ■-. F.l F.2 or F.3 above, ar explanatory statement must be attached to this EDS.
CERTIFICATION
Under pcnct:\ oT periurv the person signing below: i l l warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2,1 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.
HAL SERIES ACQUISITION. LLC SKYWAY
(Sign herei
Randail Langer t"Print or type name of person signing)
Manager (Prinl or type title of person signing)
at C.K.
County T\\ i fry;; S (stale).
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFID.OTT APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
Tbis Appendix is to be completed only by (a) the Applicant, and (b) an.v leSal entity which has a direci ownership interest is tbe 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 Murucipa. Code Section 2-154-015, the Disclosing Parry must disclose whether such Disclosing Parr> or am "Applicable Party" or any Spouse or Domestic Partner thereof currently ohs a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party'- or any Spouse or Domestic Partner thereof is reimec to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew. grandparent, grandchild, father-in-law. mother-in-law, son-in-law, daughtcr-in-iaw. stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
'.Applicable Parry*' means (i I all executive officers of the Disclosing Party listed in Section Il.fl.) .a. if the Disclosing Party is z corporation', all partners ofthe Disclosing Party, if the Disclosing Parry is a genera! partnership: al) genera! partners and limited partners ofthe Disclosing Party, if the Disclosing Parry is a limited partnership: all managers, managing members and members of the Disclosing Party, if the Disclosing Parry ;s 2 limited liability company: (2) all principal officers of the Disclosing Party, and (3) any person having more than a "".5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Docs the Disclosing Parry or any "Applicable Party'' or any Spouse or Domestic Partner thereof currently have a.'Tamiiial relationship" with an elected city official or department head?
I )>« [x] No
If yes. please identify below (11 the name and title of such person. (2) the name of the legal entity to which such person is connected; (5) the name and title ofthe elected ciry official or department head to whom sucn person has a familial relationship, and (4') the precise nature of such familial relationship.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
- Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
4000 E. 106th St LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
- [ % the Applicant
OR
- [] a legal entity holding a direct or indirect interest in the Applicant State the legal name of the
Applicant in which the Disclosing Party holds an interest: ,
OR
3. [ ] a legal entity with a right of control (see Section 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: PO Box 4855
Thousand Oaks, CA 91359
- Telephone: 818-340-3366 Fax: 818-340-3377 Email: hrrra@hotmail.com
- Name of contact person: Howard Rubenstein _
- 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):
File: 08-10-13-3605
G. Which City agency or department is requesting this EDS? N/A
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
Page I of 13
SECTION II DISCLOSURE OF OWNERSHIP INTERESTS
A. MATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person Limited liability company
[] Publicly registered business corporation [] Limited liability partnership
[ ] Privately held business corporation [ ] Joint venture
f] 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 slate (or foreign country) of incorporation or organization, if applicable:
IL
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in tbe State of Illinois as a foreign entity?
[ j Yes []No t ] N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below the full names and titles of all executive officers and all directors ofthe 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 ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalfL
Marac Title
Hnwarri Ruhqnstein Managing Partner
Phyllis Rubenstein ; Managing Partner
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. Examples of such an interest include shares in a corporation, partnership, interest in a partnership or joint venture,
rage 2 of 13
interest of a member or.manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None," NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal.Code"'), the City may require any sucb additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage. Interest in the
Disclosing Party
HnwarflRllhftnstftin PO Rov 4855 Thousand Oaks CA 91359 50%.
Phyllis Rubenstein PO Box 4855. Thousand Oaks, CA 91359 50%
SECTION HI - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[JYes , [XNo
If yes, please identify below the namc(s) of such Cily 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; (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V CERTIFICATIONS
- COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[]Yes .[^No [] 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 [JNo
- FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compbance timeframes in certifications 2 and 3 below.
Page 4 of 13
2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section H.B.I, of this JGDS:
- 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,, stale 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 ot 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 Pany, 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 ot any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (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, ot, 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 ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
- 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 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 tbe Municipal Code.
- If the Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
Page 6 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this 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 (it) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
3. The Disclosing Party certifies that the Disclosing Party (check one)
[]is [Xis not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We axe not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affiliates is, and none of. them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofthe 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) ofthe 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 ofthe Municipal Code have the same meanings when used in this Part D.
- Jn accordance with Section 2-156-110 of the Municipal Code: Does any official or employee ofthe Cily have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[JYes [KNo
NOTE: If you checked "Yes" to item D.I., 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 ofthe City (collectively, "Cily 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 [)JNo
- 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.
. The Disclosing Party verifies that the Disclosing Party has searched any und all records of tlie 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 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 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 Parly means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any . person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
- The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
- The Disclosing Party certifies that either, (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe 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 befoTC it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant? [JYes . []No . If "Yes," answer the three questions below:
- Have you, developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[]Ycs []No
- Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[]Yes . []No
- Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing 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 Cily in connection with the Matter, whether procurement, Cily assistance, or other Cily 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.oig/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 yoid), 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 lime tbe Cily takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be keptcurrent for a longer period, as required by Chapter I -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.
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 tbe Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. 1. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Parly 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, accm-ate and complete as of the date furnished to the City.
4000 E. 106th St., LLC
(Print or type nameof Disclosing Party)
By: \UJ fr/UV'C
(Sign here) Howard Rubenstein
(Print or type name of person signing)
(Print or type title of person signing)
Signed and sworn to before me on (date)
at County, (state).
; Notary Public.
Commission expires: :-
_ ' L< ' :■ f
O'A
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A
FAMIIJ AL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sisler.
"Applicable Party" means (I) all executive officers ofthe Disclosing Party listed in Section TLB. 1.a., if the Disclosing Party is a corporation; all partners of the Disclosing Parly, if the Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a,"familial relationship" with an elected city official or department head?
{ ] Yes [ XNo
If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
State of California County of Los Angeles
Subscribed and sworn to (or affirmed) before me on this 17th
day of May , 2013 , by Howard Rubenstein
proved to me on the basis of satisfactory evidence to be the person(^ who appeared before me.
JOHN P. TATA
NOTARY PUBLIC - CALIFORNIA COMMISSION « 1995144 LOS ANGELES COUNTY
My Comm Exp. November 21. 20'
syrii
(SSSTf
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. Jf unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFI CATION
Generally, for use with City Council matters. Not for City procurements unless requested.
This recertificalton is being submitted in connection with A\jAa | flCuXlLA-Stllo^tUli*Ot~L TnU fA o .
[identify the MatteT]. Under penalty of perjury, the person signing below: (l) warrants that
he/she is authorized to execute this EDS recertification on behalf ofthe Disclosing Party, (2)
warrants that all certifications and statements contained in the Disclosing Party's original EDS
are true, accurate and complete as ofthe date furnished to the City and continue to be true,
accurate and complete as ofthe date of this recertiti cation, and (3) reaffirms its
acknowledgments.
4um. \t)MU &y(JLC. Date: f^-/3
(Print or tvoe leeal name of Disclosing Party)
By: ,Hb^V^J^ul<^iA^Ar4/ IAAzua^M^L
(sign here)
Print or type name of signatory:
Title of signatory:
Signed and sworn lo before me on [date] _
/-j>(?^>A7ij? /<^^^7/Jt/; at i^^Ak'T (/(aCounty, x/z^rf^^A [state]. <d>^/ft***" / ■
A^T'tlM'k^^ltf Notary Public.
Notary Public - California z Ventura County My Comm. Expires Jul 12. 2016
Commission expires: 0 A/2 " . Commission # 1982149
Vtr. U-oi-os