Office of the City Clerk - Record #: SO2014-6678

• Record #: SO2014-6678
• Type: Ordinance
• Status: Passed
• Intro date: 7/30/2014
• Current Controlling Legislative Body: Committee on Finance
• Final action: 9/10/2014
• Title: Third loan restructuring for TWG Kedzie LLC related to rehabilitation of building at 4631-4637 S Lake Park Ave
• Sponsors: Emanuel, Rahm
• Topic: AGREEMENTS - Loan & Security

Date	Journal Page Number	Action By	Action	Result
9/22/2014		City Council	Signed by Mayor
9/10/2014	87191	City Council	Passed	Pass
9/9/2014		Committee on Finance	Recommended to Pass
7/30/2014	84529	City Council	Referred

 

i      CHICAGO September 10. 2014

To the President and Members of the City Council: Your Committee on Finance having had under consideration

A communication recommending a proposed substitute ordinance concerning the authority to enter into and execute a Loan Modification Agreement with TWG Kedzie LLC.

02014-6678

Having had the same under advisement, begs leave to report and recommend that your Honorable Body pass the proposed  Ordinance Transmitted Herewith

of members of the committee with      dissenting vote(s

This recommendation was concurred in by      

Respectfully submitted

 

(signedJ^Q^ ^>

Chairman

Document No.

REPORT OF THE COMMITTEE ON FINANCE TO THE CITY COUNCIL CITY OF CHICAGO

C3>

 

OFFICE  OF THE MAYOR

CITY OF CHICAGO

RAHM EMANUEL mayor

July 30, 2014

TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO

Ladies and Gentlemen:

At the request of the Commissioner of Planning and Development, I transmit herewith an ordinance authorizing the execution of a loan subordination and modification for TWG Kedzie.

Your favorable consideration of this ordinance will be appreciated.

 

Mayor

Very truly yours,

SUBSTITUTE ORDINANCE

WHEREAS, the City of Chicago (the "City") is a home rule unit of government under Section 6(a), Article VII ofthe 1970 Constitution ofthe State of Illinois and as such may legislate as to matters which pertain to its local government and affairs; and

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

WHEREAS, the City received certain funds from the United States Department of Housing and Urban Development to make loans and grants to expand the long-term supply of affordable housing through, among other things, acquisition, new construction, reconstruction and moderate and substantial rehabilitation in low- and moderate-income areas; and

WHEREAS, pursuant to an amending ordinance on July 24,1991, and published at pages 3593 through 3597 of the Journal of the Proceedings of the City Council for that date, the City Council of the City authorized the making of a loan to LPSS Limited Partnership, an Illinois partnership (the "Original Borrower") in the principal amount of $1,570,000, with an interest rate of one percent per annum and a term of approximately 15 years (the "Loan"); and

WHEREAS, on or about September 20, 1991, the City made the Loan to the Original Borrower; and

WHEREAS, the Loan was secured by, among other things, that certain Junior Mortgage Security Agreement and Financing Statement dated as of September 20, 1991, made by the Borrower in favor of the City (the "Mortgage"); and

WHEREAS, the Mortgage was subordinate to that certain Mortgage dated as of September 20, 1991, securing a loan in the amount of $1,262,790 (the "Original Senior Loan"), made by the Borrower in favor ofthe Northern Trust Company (the "Original Senior Lender"); and

WHEREAS, the proceeds of the Loan were used to provide for the rehabilitation of a 65-unit building located generally at 4631-37 S. Lake Park Avenue, in Chicago, Illinois (the "Property"); and

WHEREAS, pursuant to an ordinance adopted on May 7, 2003, and published at pages 173 through 176 of the Journal of the Proceedings of the City Council for that date, the City approved a restructuring in connection with the Original Senior Loan in a manner which (1) extended the maturity date of the Loan, (2) altered the repayment terms of the Loan, (3) waived then-accrued but unpaid late charges, (4) forgave then due but unpaid interest, (5) ratified a replacement general partner of the Original Borrower, and (6) subordinated the Mortgage to all liens securing the new senior financing ("First Restructuring"); and

WHEREAS, the Original Borrower entered into the First Restructuring; and

WHEREAS, the Mortgage was subordinate to that certain Mortgage dated as of May 20,

1

2003, securing a loan not to exceed the amount of $1,083,000 (the "Second Senior Loan"), made by the Borrower in favor ofthe Illinois Housing Development Authority ("IHDA"); and

WHEREAS, the Original Borrower met with certain financial difficulties in the operation of the Property, defaulted on the Loan and transferred the Property to TWG Kedzie LLC, an Illinois limited liability company (the "Current Borrower"); and

WHEREAS, the manager of the Current Borrower is The Wolcott Group Inc., an Illinois corporation (the "Manager"); and

WHEREAS, pursuant to an ordinance adopted on January 11, 2007 and published at pages 96227 through 96230 ofthe Journal ofthe Proceedings ofthe City Council for that date, the City approved a restructuring in connection with the Second Senior Loan in a manner which (1) did not alter the principal amount of the Loan, (2) reduced the interest rate on the outstanding principal amount of the Loan to 0% per annum, (3) extended the maturity date of the Loan, (4) altered the repayment terms of the Loan, (5) waived the late charges accrued as of the closing date of the restructured Loan, (6) forgave the aggregate amount of the due but unpaid interest under the Loan, (7) authorized the assignment ofthe Loan and any instrument related to the Loan from the Original Borrower to the Current Borrower, and (8) subordinated the Mortgage to all liens securing the new senior financing ("Second Restructuring"); and

WHEREAS, the Current Borrower entered into the Second Restructuring; and

WHEREAS, pursuant to the Second Restructuring, the Mortgage is subordinate to that certain Mortgage dated as of February 27, 2007, securing a loan in the amount of $2,000,000 (the "Third Senior Loan"), made by the Current Borrower in favor of ShoreBank, an Illinois banking corporation, now known as Urban Partnership Bank; and

WHEREAS, the Current Borrower now desires to refinance the Third Senior Loan by entering into a new senior loan in an amount not to exceed $2,000,000 (the "New Senior Loan") and to execute a mortgage (the "New First Mortgage") in connection with the Property in favor of a new senior lender (the "New Senior Lender") and has requested that the City approve another proposed restructuring of the Loan; and

WHEREAS, the City's Department of Planning and Development ("DPD") desires to approve another restructuring (the "Third Restructuring") ofthe Loan in a manner which (1) will not alter the outstanding principal balance or interest rate of the Loan, (2) will consent to the New Senior Loan, (3) will extend the maturity date of the Loan, (4) will subordinate the lien of the Mortgage to the lien of the New First Mortgage, and (5) will alter the repayment terms of the Loan (collectively, the "Material Terms"); now, therefore,

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

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

SECTION 2.  The Third Restructuring is hereby approved as described above. The

9

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A,      LcgtiJ name of thoTJisclp'sirig Pariysubnljttiiig this EDS _r Include, d/b/a/ if applicable:

TWO KEDZIE LLC

Check ONE of the following three boxes?

-Indicate^whetner the Disclpsihg Party stibmittuig this EDS isi ie; Applicant OR.

fj a legal entity holding a director indir^fitintetesfuiihe Applicant. Sla,te the. legal narne of file

Applicant in .which theDisclosing Parly holdsnb ibterestt^      ...             

OR

3. ['] a legaleuti^                                                  Statethe legal naine of the entity .in

which the Disclpsing Baf ty boldS a. right oficontrol: .       

,      ,      935; W: Chestnut Street, Suite 600

B.      Business address of the-Disclosing Party:      - ■      

Ohloa^,, Illinois 60642

(3i2)477r28i23'      . . (312)226*8900'      ., victor@wblcottdrotlp.rtet

1. Telephone:      „      Fax:       ; Email:. -

_ _v        „      Victor Michel

1. Name or contact person:      ;      

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

1. 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):

Applicant is seeking Ihe City's approval.for resubordinatlon of the Cityls Second Mortgage for 4631 S. Lake Park, Chicago; IL

, Department of Planning and' Development

1. Which City agency or department is requesting this EDS?      

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

Specification U _;      and Contract #      

Ver. 01-01-12      Page 1 of 13

t

SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A NATURE OF THE DISCLOSING PARTY

I.   Indicate the nature of the Disclosing Party:

[] Person      /rpjNL;iiiiited Ifability company

[ ] Publicly registered business corporation      [.j Limited liability-partnership

[ ] Privately held business corporation      .[ ] Joint .venture

[.] .Soleproprietorship      [ ] Not-lbivpipfir.cpipotaliori

t ] General partttersbip      (Js•jfre,nor-fi>>^^      also a 501(c)(3))?

F] Limited partnership      ;[ 1 Yes      [ j Np

{ } Trust      [;] Qtber (pltiia.se speci fy)

2,      For legal entities;, the $l*i(&(dr Coreigri rfbuntfyj      or organisation, if applicable'

Illinois      .

3.      FoJ' legal entities riot organized in-the Stat&.COf Illinois; Has the organization registered to do

business bi- the State ciE111 iri6i& ^s:*. fbreig^t ^ii

 

[JYes      NNo ^N/A

B. IF THE DISCLOSING PARTY TS A LJEGAL ENTITY:

1. List below lhe full names and.titles of'aliex.e,cUtiv_te officers- and all directors ofthe entity. NOTE: For notrfor-profjt corporations, also, list belpAv all rhetribers, if any, which are legal: eiititres. 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 ilatne and title of each general partner, managing member, manager or any other person or entity that.corttrols the dayvto-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title The Wolcott Group inc. Manager

Brinshore Development LLC      Member- 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% ofthe Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,

Page 2 of 13

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

Name      Business Address      Percentage Interest in the

Dfeclosilvg Party

Andrew S. Goodman Revocable Trust dated January 15,. 2PQ2      % Chestnut. Suite GOP, Chicago, IL 60642 15.033%

Arl Gotson Revocable Trust dated August20,2004- 935W. Ches.triul, ^tiite 6Q0, Chicago, IL 606.42      -15:833.%

^idlo^; Michel, Declaralton#^ 15.833%

Brinshore Development LLC-666 Dundee Road;. Suite 1103/NQr3h'P^^      ■      42,50%-      

SECTION Ut— BUSINESS IIEJjA^

H-as the Disclosing Party had 4 "bustfifH^s/^      pf lhe Municipal

Code, with any City elected official in the li months? before tfie dahi this EDS, is signed?

[j Yes      />jj No

If yes, please identify below t)teVntime(5^ ofa^ rjelationship(s):

SECTION IV — DISCLOSURE OFSIIRGbNTR^^TjORS AND 6T/HE.R RETAINED PARTIES

The Disclosing Party must disclose thename imti business, address, ofeach subcontractor, attorney, lobbyist, accountant, consultant .arid any other person Pf entity whbni the Disclosing Parly has retained or expects to retain in connection with the Mattei, as: weti as the nature of the'relationship, nnd the total amount ofthe fees paid or estimated to bjepaTd.- The; Disclasihg'Parity is; h'ot required to disclose employees who are paid solely through the Disclosing Party's regulai; payroll.

"Lobbyist" means any person or entity who undertalees to influence any legislative or administrative action on behalf of arty person or entity other thanf (!) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or ehfity 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, Ihe 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)

"^sGjieck here if the Disclosing.Party has not retained, nor expects to retain, any such persons or entities.

SECTION VCERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

UnderMuniQipai Code Section 2-92-415, substantial, owners of business entities that contract with (lie City must remain: in compliance With their child support obligatibiis throughput the contract's term.

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

[ ] Yes

 

[ ] No person directly or indirectly owns 10% or more' ofthe 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?

[JYes

 

B;. FURTHER CERTIFICATIONS

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

Page 4 of 13

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

1. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
2. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense,, adjudged 'guilty* or had a civil judgment rendered against them in. connection with': obtaining, attempting to obtain,, or performing a public (federal, stale pr lpc;al) traflsa'ctiptt of. contract undent¹ A public, trausactiori; a violation of federal Or state antitrust statutes; fraud; cnibezzlpoieht; theft; forgery; bribery; falsification pr destruction Pf records; nVaTcirig false; statemertfjs;, prrecetving stolen property;

p.   are 0ot'pf<^ndyan4ict«4^:i'0r>or%crjnitbtrlj.y or civilly charged by,, a govetnjnentai'ertrity^/(federal, state orlocal) wi^

1. have not, within a five-year period preceding the date of tbU'^SyJijsd'^-Pfmtic^pu^Tii^ transactions (federal, state oi: local) terminated for pause or default; and
2. have not* within a fiyenyear .period preceding the date of this BDS, been convicted, sdjtidgetf guilty, or found liable id a civil proceeding, or in any criminal or civil aptioji;.jncJudih^ach^hs concerning enviTPnjnehiaJ violations, instituted by the City or'by tftfc federal gpyexhriiient, hhy state, pr any other unit of local government.

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

⁴      the Disclosing Party;

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

Page 5 of 13

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

a'., bribed or attempted to bribe* or been convicted or adjudged guilty of bribery pr attempt ing to bribe, a piiblic,officer oreiiiployee of the City, the State of Illinois, Or any agencyojf the federal, government or of any state pr local, government in the United States of Aniertca,, in f liar officer's; or employee's officigl eaRacity,.

,or cfe-br

b. agreed qt colluded. w-itj\ other bidders ox pjpspebtive bidder^ or been, ft party tp .^ftyt siicjh) agreement, or been ebovijctbd •6r*^tt<lged^uilty'.ibf agreement ojp ^ojttu^4vl.iAo^<^f prospective biy.ders,_/to^ otherwise; or.'

e.  niadeaii admission of snbk e.o.nduef described" in a. or b. above that is a niatterof ire^^ have not been p|o'sc]0j^4;^Hucij. tjondupt; of

ci. yioiated'the provisions of Municipal Code Section 2-92*6iQ (giving Wage; Ordinance;)

4'.  Neither the      pr Contractor, 6farty^

agents or partnters, is barred^

engaging in or .b.ein^ctiavi'eted OJf {lJbid-riggirig in violation :qf 720 LLCS Si^B^^yH^tt^M^

yioiaiipu pf? 720 ILCS 5?33Bf4; of.(3^      ofany state or of th&Unit&d Sfafes df

America that contains l\\h same elements as the offense of bid-rigging prbid-rottttirig.,

1. Neither the Discio'sjngiParly nor any Affiliated Entity is listed on any ofthe foilbiyingilists maintained by the Officev of Ppreign.Assets. Control of the U.S. Department of the Jreasuty Pf the^-Bureau of Industryand Security ofthe U.S. Department of Commerce or their stipee'ssors:' ffje Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and tb> Debarred List.-
2. The Disclosing Party understands, and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
3. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

ertificatiqus), tl

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 (he Disclosing Party who were, at any time during tile 12-* month period preceding-.tlie execution date of this EDS, an employee, or elected or appointed' official; ofthe City of Chicago (if ndnei indicate with "N/A" or "none").

r tne t-n

4/

9 Tb thejbestbftke:Dis^ complete list.of all gifts that jhe-.Disclosing Patty has giyen-pr caused to 'be.-giVteft,,^ IZ-menth peirbd preceding' the etfeputibn date of this EDS, to alt employee, pr elec^te^ .o^^^pihM offic)lal,.of the City of Chicago. For purppses of this, statement,, a "gifP daes nPt-^ made generally.available to Chyveniployees.or to the. general public, or (ii) food '6r/dfiujt'|ifrbyjb!ed ih thev Course¹ of official City business andhaving a retail value of less Uiiin $20 p.ei- recijpien((if npue^Jn >Vith'"N/A^ or ^,fnoiie"). As to any gjfr listed below,,please also list the name ot'theCity feci^ient;

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1 v The DiscIosing Party certifies that the DiscIosing Party (check one) [Jis P^not a "financial institution'' asdefinedin Section 202-455(b) ofthe Municipal: Oode.

2.   If the Disclosing Party IS a financial institution, then the Disclosing Parity pledge's;

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

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

i-32 of tlie-Municipa

Page 7 of 13

If lhe 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 CtTY BUSINESS

Arty \vords pr terms that are defined in Chapter-2-156 ofthe Municipal Code have,the, same mfeoriiirgs when.irsed' in- this Pari p.:

1.      in accordance \yith ;Secti^^      0o#e^pqe#-:a.n?p|[i$j3|to*gmpjflyeft-

pftjjkCity h?w'»l|ft»n$iatintsf^sf yt&fo oijvitbwiji name orin the namfe of miy^

eutjty'bvthe Matfef?-       \ r

H Yes |pb

iteiTi'D. 1proceed to Part Ev

2,      Unless sold puisuanMp a process of competitive bidding, or otherwise perjuitted, h.6v!^iiy

elected official'premployeeTsjiaiHiawe a fmatieial interest in his,or iter o>vo;W9iae'pj; in .&ej-;pstfi&fc£

any bther pcrspti or entity in tlte jpurcJiMe of any. property that (1) belongs fo the City'; or fji^^bld:

for taxes>op assessments, or fiii) is;gq.l'a\ by Virtue pf legal process at theauitof the-Qity; (cpjiectiyiily,,

"City Property S<tie");. Conipeinsatipn fjtt prbpetfy taken.pufsuant tp tlie City's eiument dolbain gp'V/er.

does hot constitute a flnaupia'l interest Vvitfiin the ineaiting of this Part D,

©pes the Matter involve a City Property Sale?

 

[JVes

3. If you,checked "Yes" to Item DU., provide the names and business addresses of the^:Ci.ty Officials, or employees having such interest and identify the nature of such interest:

Name      Business Address      Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

1. The Disclosing Party verifies that the.Disclosing Party has searched any and all records of isclosing 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 re.dords.

^      2. The Disclosing Party verifies that,.a> a result pf conducting ,tha search in step 1 abpve. the

Disclosing Party: has found repp^dsvp^      0qin s.laye>;y or slavehplderinsurance:

policies, thei-Di^loslftg.Pi»rlx-Ve^iti^Allt¹^ i^nQWfn&^Stttut^CuU •dfe^pStrfe.of•sjU-AUefi recprds,-;ineiuding the- names of any afto* jffiUistoe^drKsla-Y^hpide^ described in thbse records: j

section vi - CEftTiiPiCA^iO^ ^oic 3fe^iiAlly funded Matters

NOTfc If the Matter is federally ^unttett, .ggmptefefi& Section Vl, if the. Matter is not federally

funded* proceed tp Section VII, Fpirpurjj^^^      fax credits allocated by the City

and proceeds pf debt pblig^^^ fiindlng.

A. CERTIFICATION REGARDINGLOBBYING;

1.   List below the names bf aU persbhS o^ Lobbying

Disclosure Acfof 1995 who haye made lobbying contactson. behalf ofthe- Disclosing Party with

respect .to the Matter: (Add sheets if necessary):

M [$r-      1      .      

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

2.   The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or enlily listed in Paragraph A,I. above for his or her lobbying activities or lo 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 ofCongress, an officer or employee of Congress, or an employee of a member ofCongress, in connection with the award ofany 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

1. The Disclosing Party will submit an updated certification at'the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set ■forth in paragraphs A.l. and A.2. above.
2. the Disclosing Party certifies that either: (i) it is noi an organization described m section SO I (c)(4) of the Internal Revenue Code of 1986;, or (ii) it'is an Organization described in section 50i(c)i(4) of the Internal, Revenue Code of i986 but has not engaged and wiil>not engage in¹¹ Lobbying Activities",
3. If the fjis.closing Partyis. thts Applicant, the Disclosing Party injai^t,-ijjjicai»: ceiirfflSlqiati.ojrt^ equal ,in fprm.and substance tdf paragraphs AJ) through • A.4. -a&ifcvs ftp'tft aft ^ubCc.Q^t^^tjgtis^'ci^ojr^:it:-sASvn^dl*-*oy^: subepufract and tl^b Disclosing Party mtis;t maintain all snpb siibc^

■duration of thtf-Matte.r an^^

PL CERTIFICATION REGARJ3ING EQUAL EM PLQYMENT' QP.PORTUBltfY

If the/ Matter is federallyfunded, federal regulations, require-the Ap^

subcontractors to submit.thjj, following information with their biifs-drift*waitingal    outset of.

negotiations.

i^.tiie Disclosing Party the Applicant?

[]Mo

if "Yes,"i(hswer the tiiree questions below:

1. iiave you developed and doypu have on file affirmativeacfiotiprdjgratns^pu^sUsuir.t©applicable: federal, regulations? (Se;e 41 CFR Pari 60-2.)

[ ] Yes []N0.

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

[ ] Yes      [ ] No

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

[ ] Yes      [ ] No

If you checked "No" to question 1. or_2. above, please provide an explanation:

Page 10 of 13

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

'Hie Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will'become parVof any contractor other agreement between" the Applicant and the City in. connection■ with the Matter, whether procurement, City assistance, or otherCfty action, and are material inducements to the City's execution; of any contraot or taking other action \yith respect to the- Matter, The .Disc losing Party Unde.rstauds that it must comply \yitb all statutes^ ordinances, and regulations.on which this, ETJS is based.

B_v "The: City's Governmental Ethics andCampaigrt Financing Ordinances, ^apters- 24'56ja"ndv the Municipal Code Jmppsre certain dutie^a

wprk_r b.usinessi or transactions. -$jtfe'jfa[fi tejtt of 1be$e pfdinSnces and-a trailingprogram & waji$bi$$i line' at wwwxityofchicagoVore/Eu'licsvahd may sTsp be obtained from the City's Board ^of^|h^,74:6'^-

Sedgwick St., Suite 5.0p,» qi.i|pajgo,.^-'SO$|0» (312) 744-9660: The Disc losing Party must bo.mply fnljy. Wjtll the applicable ordinances,

Cv If the City determines tXat any information provided in this EDS is false, incomplete or: inac.^nrate,,

any Qpntractoipthe^ agreerb:e      be resemdedorr^^.^oiU <jf

voidable,, and the City may pursue .anyferiiedieS under the .contract, or agreement (if hbt rescindetl pr; yoid), atlaw, or in equity, iuahidtng teniiiAating the Disclosing Party's participation iii Oie'Maiter ahtJ/pr declining to allow the Disclosing Part^ tbp.4f tibipat^ in other transactions with the City. Remedies, af Law for a false statement of mater ial fact ittay include incarceration arid an award, to ihe.City of ffeplb; damages.

D.      It is the City's policy to make this document available to the public on its-internet site, and/pr upon

request* Some pr all of the information, provided on this EJ>S and any attachments tp this EDS may be

made available to the public on die Internet, in response to a Freedom of Information Act request, pr

Otherwise, By completing and signing this EDS, the Disclosing Party waives and releases, any possible

rights or claims which it may have against the-City in connection with the public release of information

contained in this EDS and also authorizes the City to verify the accuracy of any information.submitted

in this EDS.

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

Party must supplement this EDS up to the time the City takes action on the Matter, if the Matter is a

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

update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of

Chapter 1-23 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 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F. I.    The Disclosing Parly is not delinquent in the payment ofany 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 oilier charge owed to the City. This includes, but is not limited lo, all water charges, sewer charges, license fees, parking tickelSi property laxes or sales taxes.

F.2    If the' Disclosing Party is the Applicant, the DiscIosingParty and its Affiliated Entities will not use, nor permit, their subcontractors lo use, any 'facility- lifted by'the U.S. E.P.A. on the federal Excluded. Patties-lust System ("EPLS";) maintained by the U. S. ~General:Serv.ices Administration:

F.3    If thesDisclbsfng; Party is the: Applipant/fhe. Discltjsjng Party wi|l obtain from- any

contractors      conneetion with the Matter .certifications equal in _:

fprnvaiid substance td tltpsji foppjv gftjf ^.ajb^Vjft^d wilt n$t> Without the prior written, dons^fcof the

City,^      eettifi'catl.ous:'br;tha;t the

Disclosing P&c^h^'^eift§pji*t9f' j^Cc^V^'Jifl^ -ilij^-peiJSVf^igct $ri$'a;nii0t jtoYffle:iruthfuf^: cetttfiSsattdrts?

NOTE: If the Disclosing Party batmpt certify as tb any of theitems in F.L, F-.2. prF.3. above^ an, explanatory statement must be attached, to ihi^ EOiS.

CERTIKlCATrON

Under penalty orper4Ufy,.t&e per$bu sjgrfutg below: (^warrants, that life/she isl atithfit^d^o/ie^fcii^ this fifiS and Appendix

certifications and sta{enten.ts.t;b4it3inftd1iithis; BPS and Appendix A (if applicable) are true* aeourafe; and complete as of the datefitfnislied tp th^ G'ity

TW(3 Kedzie LLC", by The.WofcoK Group, inc. Pop pf Its Martyrs

(Print or type name pf Disclosing PaTtv) By:

(Sign here) victor Michel

(Print or type name of person signing)

Treasurer of The Wolcott Group Inc.

(Print or type title of person signing)

Signed and sworn to before me on (date) July 10.2014

at Cook      County, JL      (slate).

Molaiy Public.

OFFICIAL SEAL" SHANNA Q. LOVE Notary Public. Slale of Illinois ' My commission expires 10/28/17 J

Page 12 of 13

Commission expires: October 28. 2017

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFIOALS AND DEPARTMENT HEADS: This'.Appendix ; i$ to he completed only byXa) the Applicant, and (p).any legal entity which has n direct

 

or any '"ApplicabtePar^'oranySp^ any elected city official or departmeht bead, A ^filtnilial relationship" exists if, as. of the date this EDS is , sigiied, the Disclosing Party Or any ^Apniicable PHrry" pr-anySpouse pr Domestic Partner thereof i&jfrjtttgd' jO, fheiu'ayor, ariy aldemian, the city cifcrki' the city tje^stif er or any city depailtnent head as spouseor doinestic-partner lor as any of the following whether by bipod or adoption: parent, child,, brother or sister, aulitpr- Uriels riieee-pTnephew, grandparent, gra'ii^

ofs.teptnPther, stepson or stepdaughter stepbrother pr stepsister pr half-brother or>balf>sisteri '%plicable Party*^^

Disctbsing Party is a corporation; allpartner^offne bischDsing Party, iffilie Disclosing Party is* genera) pafirteishiplaligeneral part^

partnership; all managers, managfog members and nwttlpftr^bf the Disclosing Partyv.if the Disclosinjg; Parryis/n limitecl liability company; (2) all prmcipal officers of theiDiscjosing Party; and (3) any person having moj-e than a 7.5 percent ownership intwsf'itt'th'e^iscUj^g^f^. "pjfjajejpa.l OfJQeers" means the.presidentv chief operating officer, executive director, cbief financial officer, treasurer or secretary of a legal entity or any person exeixnsing similar authority.

Does the. Disclosing Party or any "Applicable Pairty'Vor any-Spouse Or Doinestic Partner thereof currently have a "familial relationship" With an elected city official or department head?

 

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AMD AFFIDAVIT

SECTION I -- GENERAL INFORMATION

1. Legal iiame ofthe Disclosing Party submitting this EDS. Include d/b/a/if applicable:. The Wolcott Group Inc.

Check ONE ofthe following three boxes:

.Indieate whether the, Disclosing Party submitting this EDS is: I. [ ] the Applicant OR

2... HPla legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthe

Applicant in which the Disclosing Party holds an interest: TWG kedzie LLC      

OR

3. [ j a legal entity With a right of control (see Section ILB. 1.) State the legal name ofthe entity in

which the Disclosing Party holds a right of control:      

935 W. Chestnut. Suite 600

1. Business address Of the Disclosing Party:       -_

Chicago, Illinois 60642

(312)226-2200      (312) 226-8900 vtrtor@voto6llgr6op.ncl

C. Telephone:      Fax:      Email:      

Victor Michel

D. Name of contact person:      

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

1. 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):

Applicant is seeking Ihe City's approval for a re-subordination of the City's Second Mortgage as part of a refinance of the First Mortgage

1. Which City agency or department is requesting this EDS?       

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

N/A N/A

Specification ft            and Contract fi      

Ver. 01-01-12

Page 1 of 13

SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A, NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing P> f ] Person

 

Publicly registered business corporation Privately held business .corp^faUoii [ ] Sole proprietorship [ ] General partnership [ ] Limited partnership { ] Trust

2,, For legal entities;,- the state•^r.foife'ign t

t'ty:-

[] Limited liability company

'[J Limited liability partnership

[ ] Joitit venture

[ ] Hot-for-profit corporation

(Is the rtOt-for-prb.fit corporation also a 501(c)(3))?

[ ] Yes      [ ] No

.[■] ,Dther (please specify)

&iunl^

minors

3.  For legal" entities; notorganized, in the: State ofillmb isi Has the: organization registered to do business in the State pf Iliiuors>as *-f^r^

LJ Yes i)Mo

B: IF THE DISCLOSING PARTY'ES A\LEGAL.ENTITY:

1»< List below the full n.ame$ arfd titles Of all executive officers; and all directors of the entity.

NOTE; Feu* not-for-profit spippi^^      if any, which are legal entities, if

there are no such members, write- ^!'np-members,;ⁿ' For trusts, estates or other similar entities, list below the, legal titleholder(s)_;

If the entity is a general partnership, liniifed partnership), limited liability company, limited liability partnership-or joint venture, list below thenamei and title of each :general pari tier, managing member, manager or any other person or entity that controls the day-to-day management of the.Disclosing Party. NOTE: Each legal entiiy listed below mustsubmitan EDS oit ifs-own-behalf.

Name Title Ari Golson President

Andrew Goodman Secretary

Victor Michel Treasurer

No Directors

2.   Please provide lhe 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,

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 tp achieve full disclosure.

Name      Business Address      Percentage Interest in the

,Disc;losing<Party

Art Golson. 935 W, Choslnut, Sle:$o6, Chicago, H,'6Q643 "      ,33.33%       

Andjey Goldman. 935.W,C^       33.33%      

Victor Michel, 335 W.Chestnut, file 600^.Ctiie^^ip6P^2; -            . 33,33%      

SECTION IU -- BUSINESS RELATE      ELECTED OFFICIALS

Has the Disclosing Party im&a ^      in Chapter 2^-156 of the Municipal

Code, with any City elected pffieiaifn tlte. 12 ltlbnths-hefote the^date this EDS is signed?

[]Yes      ;/No

if yes, please identify below (he.tiM'toB^¹)'^^a^tL-"Ci"fy. elected -wjESciaflfff) abd describe such relationsMp(s):

SECTION IV - DISCLOSURE ^F S^CO^TRACTORS AND OTHER RETAINED PARTIES'

The Disclosing Party must disclose thername.arid businossTiddress of each subcontractor, attorney,, lobbyist, accountant, consultant ttnd.any\pt'henperspn or entity, whom the' Disclosing Party has retained or expects to retain in connection \yitlvfli'eJyfa'Uer^.as well as the nature of the relationship, and the total amount ofthe fees paidpr estimated tp b&p.aidi The Disclosing Party is not required to disclose employees who are paid solely through the DisGlosiiig Party's regular payroll.

"Lobbyist" means any person Or entity Who undertakes to influence arty legislative or administrative action on behalf of any person pr entity other than; (1) a not-for-profit enlity, 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 slieejs ifnecessary)

j^jch'eek fieri' if the DTsdlosing jBaftjri'has.liOi reraine^, nor expects to regain, any such persons or entities SECTION V - CfiR^JFIGATIQISfSr

1. CO.URT-QRDERRD CHILD S.UFjPOR.T COMPM A#C$

Under Municipal Code Sefciian;^^      <5wners4f business, entities that contract \vh'h

the City must remain in CompI^^      the contract's term.

Has any person who directly ^      Disclosing: Party been declared in

arrearage on any ohitd support obligatioris'by; any Illinois coiirLof;eornp/etent jurisdiction?

[ ] Yes      t i^;'^d.^cctly>briiidireCtly owns 10% or more ofthe

■ ,Disclositt^at|y.

If "Yes," has tlve person entered lAto.'ii-4M\j^^p^Ve^d*a'gre^.eh.t fOr payinent Of alt siipport owedand is the person in compliance with that agreement-?

[]Yes f/Jlo

1. FURTHER CERTIFICATIONS

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

Page 4 of 13

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

1. ate not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
2. have noL within a five-year period preceding the date of this EDS, been convicted of a criminal

offense, adjudged guilty, or had a civil judgftient rendered against them in connection with:

obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or

bbntractunder a.pnblic transaction,*,ay^atiOn pf federal or state antitrust statutes; fraud;

enthefcaleinen^      of records* making false

sJateniejits; or receiving stolen proper(yj:

c.      . ate not presently indicted fpr,_ror'erin^inaOy. prcivilly charged by j a governmental entity (federal,

state or local) with cp^imitttnguity^'f tt^Slilifl^^ib^^ clause B«2>b p'f this SectiPh Yi.

1. 'have.-trot, Within a five-year period;pfePidrngCthft da'tj;. of thi&EDS,,3ia&o.rtfcor more public transactions (federal, slate tsi ib.car) tJJrinin&ted for cause Or default; and
2. niavC hot, within a five-yearperi

guilty, or found liable in a eiyil^pae.eiin^ or in any cruriinal pr civil action^ including actions,

cphoerning ehyirohmenfal viplations^      or by thfefedernl government; arty

atate, or any otherxmit of local government.

1. The certifications in stibparrsrt, 4 and 5 concern:

*      the Disclosing Party;

♦      any "Contractor" (meaning any contractor pr subcontractor tised by the Disclosing Party in connection with the Matter, ihcluding but jiot limited to ail persons or legal entities disclosed.under Section IY, "Disclosure of SubBOhtriCtbrs and Qther Retained; Parties");

• any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is Controlled by the Disclosing Party,,.or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation; interlocking management or ownership; identity of interests among family members, shared facilities, and equipment; common use of employees; Pt 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, Ownerships or principals as the ineligible entity); wilh respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
• any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Parly, any Contractor or any Affiliated Entity, acting pursuant lo the direction or authorization of a responsible official of the Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any A ffiliated Entity of either the Disclosing Party or any Contractor nor any Agents have-, during the five years before the date this EDS is signed, or, 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 cqnlract or engagement in connection with Ihe Matter:

a^   bribed or attempted to bribe, or been convictcd or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or tiny agency of the federal government or of any state OripcaLgpvermn'cntin the United States pf America, in that officer's pr employee's official capacity,"

1. 1. agreed or colluded with other? bidders; pr; prospective bidde.rs,-of been a party to any such
   2. •agreement, or been convicted' .oracpudged guilty Of agrCejnentpr collusion among bidders- or
2. 'prospective bidder$_t inrestra      bid a fixed price or

otherwise} or

1. 1. made an admission of sncb'eondu.9.t desfenbed UV^', or^;bi>above that is a matter of record, but have not been prosecuted forrsnchJcondu'ct; or
2. violated (he prdvisions of $VmioipaliiExideSection 2-92~Bi 0 (Living Wage Ordinance).

1. Neither the Disclosing Party* A ffiliated B'ntity or Contractor, or any of their employees, officials,, agents .or partners, is' .biia'e^^>i^p.cbp.Mcti)rg:witH ^Hy^uiBft'-of itsjfe. or local government asaresult of engaging in or being convicted of ^

violation of 720 ILCS 5/33E-4:; pr:(-3^

America that contains the same elements asfthe offense-of bid-rigging or bid-rotating.

1. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control ofdie U.S, Department ofthe Treasury or the Bureau of Industry and Security ofthe. tLS^: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.
2. The Disclosing Party understands.an.d. shall, comply with the applicable, requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspecior.Generai)and 2-156 (Governmental Ethics) of the Municipal Code.

7.      If the Disclosing Parly is unable to certify to any of the above statements in this Part B (Further

Certifications), the Disclosing Party must explain below; N/A

Page 6 of 13

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

8.  To the best of theDisclosing Party's knowledge; after reasonable inquiry, the following is a complete list of all ennem employees of the Bisc.ioS.ing party ^bP were, at any time during the 12-month period preceding the execution tiate of this EDS, an eniployee, or elected or appointed official, of the City of Chicago (if notie, indiQatewith "N/A'¹ ojr '-none");

N/A

9.  To the best of'tKe Dtscipsihg'j^      inqtiiry^ the folldwirtg.'is a;

COmplefe.list of nil gifts that tlieD'isQibsing P^      to be gtyen, atany time during the

12-mofith period preceding the exefcutio^      employee, or elected oe appointed

off?ciai,,of the City of Chicago. Forpurpbses"of this sta teineril, a '^ift'^does not include: $ anything made generally available to City employees ot: to the;genetaj public^or (it) food W drink provided in the course of official City btismess-abd■ ^:havi^,«r f^tfLli' 'vrflttfe-orie^s" tha'n-.Svi"b"p-ef Mcip-tett"t (.if n'oitet, indicate with^f'N/A" Or "none"). As to any gift listed below, please also list the name of the City recipient, N/A

C. CERTIFICATION OF STATUS A;S^rPIN-ANCiAL INSTITUTION L  The Disclosing Party certifies tKat^Pis^d^^Bart^bttec^sdne)-[ ] is" [y^jisiIOt

a "financial institution" as defined in Section 2v32i455(b) of the Municipal Code.

2.   If the Disclosing. Parly IS a financial.ihstitutiOn,'tbeji the Disclosing Party pledges:

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

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

N/A

Page 7 of 13

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

a. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any-.words or terms that are defined in Chapter 2-15,6 of ti],C Municipal Code have the s.ame meanings when used in this Part EL

1. In accordance with' Section. 2-L564 10-pf 'tlie Ivfbnie.ip.a'I Cpflei Does (thy official or employee pf the City haye o financial, fiiterest itt r\is^; or K^r ^#it iiairtS: dr in the frame Of any other person; or entity in the Matter?

T}Y'es f£^o

NOTE; If you checked "Yes" tq 'ltm D. l ./proceed: tb.ftehis DA. nbd D;3v If yon checked "No" to Item D.1., proceed to Part E_r

1. tiniestsold pursuant to frproces&M      uo City

elected official of employee shall haVea: financfe.1 f&feY&ft 1n^;°hfco>n$r;oW:a name or in the name of

any other person or entity in the purchase, 6f any properly that (i)belphg$ tb the-City, Pr (ii) is sold

for taxes or assessments, or (ill) is sold by>v|ftUe';pf legitprpcess at the suit of five City (collectiveiy^

"City Property Bale"), Compensation fof ^forp&^fe^^V^«4n1 ^fP -ffce City's eminent domain power

does hot constitute a financial ibt^^Ylltoto t»V^*aSJ%^:6f'tfilis PariD,

Does the Matter involve a City Property Sale?

[ ] Yes      [7] No

1. If you checked "Yes" to ItemD.L, provide the; nanies 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

N/A

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

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

the Disclosing Party and any and all predecessor entities regarding records of investments or profits frpm slavery or slaveholder insurance policies; during'the. slavery era (inbluding insurance policies issued, to,slaveholders that provided coyerage-fbr damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

      2. The Disclosing Party verifies thatj as a'result bf condoling the sehrch in step: j above; the

Disclosing Party has found records,p.flinvestineiits.pr profits fYp)ivsjavery-prslayeliQ

policies. The Disclosing Party verifiesthat the folfo^      disclosure.of al,L-such

rec.ords,.<ihciudingthOseieeords?. ;N/A

SECTION: VI "CERTIFICATIONS FOR FEDERALLY FTJNDED MATTERS

NOTE; If the Mattettis federaljy Tiaided_ycoriipfei^      VT; ■> if tD e Matt ei' is. apt federally

funded,proceed to Section YTL ForpuippseS;pf'^      allocafed by the City

and proceeds of debt obligations Of tbe'City.are hot fe;d

A. CERTIFICATION REGARDING LOBBYING

1.  List below the names. oF all persons or entitjes^eg^ Lobbying D isclosure Act of 1995 who have made.lobbying contacts; oil behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):

N/A      

(If no explanation appears or begins on (he lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf 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 person or enlity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or enlity to influence or attempt to influence an officer or employee ofany agency, as defined by applicable federal law, a member ofCongress, an officer or employee ofCongress, or an employee of a member ofCongress, in connection with the award ofany 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

1. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe Statements and information set forth in paragraphs A. 1. and A.2. above.
2. The Disclosing Paf(y certifies ih^t:ejthecr.'^it;iB-}.^l'ah' brpntealipu described in" section 501 (c)(4) of the Internal' Revenue Code Pf 1986;; O'r (ii) itisah' orgabi^tlon desbribed iii section 50i(c)(4)pFthelnternai Reventie'Code of 1986bu>h^

Activities'¹.'

1. If the Disclosing Party is the.Appiipant, th^Msc^      equal in

form ahd substance to.paragraphs A\\ 1. through A&apb^ei^

subcoiui^pt and the Discio the*

duration of the Matter and iUUstmake snbh,cerf ifieafi^      tollie Qity upon request;

;B: CERTIFICATION REGARDING EQXIAIi^EMPLOYMENT OPPORTUNITY

If the Matter is federally .funded* federal r^gulato      Applicant and all proposed'

subcontractors to submit the. following uifbfm&t^      bids ot in writing at tbeipijtset Of

negotiations.

Is the Disclosing Parly the Applicant?, t J Yes

If **Yes  answer the three questions belowi

I.  Have you developed and do you have on file .affirmative: action' programs pursuant td< applicable federal regulations? (See 41. CFR Part 60-2.) □ Yes [/Vo

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

[ ] Yes      / Sfo

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

[ ] Yes \/}io

If you checked "No" to question 1. or 2. above, please provide an explanation: This is not a federally funded matter

Page 10 of 13

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

The Disclosing Party.understands and agrees thai:

A, The certifications, disclosures, and acknowtedginents,cpntained-in this. EDS will become part of any contract or other agreement betweenithe Applicantand the City in connection with the Matter, whether procurement, City assistance,; or other City action; and arc materiat inducements to the City's execution of any contract or taking other action With f aspect. to>jjfe$#t#' The Disclosing Party understands that it must comply with all statutes, ordinanc'es_i:ind reflations on \yhioh this EDS i$ based.

B_t The. pity's; G/overuinehfaJ Etlu^s anUCain^      2-15;6 and 3rl64 of

theMitJuVipal Code,,impose-eertain dutibs ^dbpllgatfehs 9nipe>5pns'■of emltfe&sje^r^g-cjify'cpiiira^tsi workj'business, pf transactions. The full test bf ;tKes^ ^^ix^^^1m^8^tt^inins-i>t^g^m available on Tine at^: Www:oityofchicago.orR/Ethics, and may also be .obfaine.cf froM ilie-^

Sedgwick St., Suite 500, Chicago, IL 60610, (312:)_;744-9f)6Qi The Disclosing Party must comply fully with the applicable ordinances.

1. tf the City determines that any inf^thtarioniptdv^Sf^ this BPS is faise, incomplete opinacciira.te,
2. any contract pr other agreement inebrtneods^      be rescinded or be yoid or
3. Voidable,,a.ud the" City .may pursue^ or

void), at law, or in «.qnity»jac.iad{ng.tea^^^^ 0^seifb.&ing iPdfry!s participation in the Matteriand/br

declining to allow the Disclpsibg Party #      the City. Reinediesat

jaw for a false statement of material fact may include ^      to lhe City of treble

damages,

1. It is the City's policy to make this document available to .the pUblio on its Internet site and/of upon request. Some or all ofthe information provided on this EDS and. any attachments to this EDS may be made available to the public on lhe 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 ofany information submitted in this EDS.
2. The information provided in this EDS must be.kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter, If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 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 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Parly represents and warrants that:

Page 11 of 13

F. 1.    The DiscIosing 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, ail 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 noi use, nor permit their subcontractors to. use,, any facility lis ted by the £LS> E.P.A, on the federal Excluded Parties List System .C^,rEPLSⁱO iuamta.:ioed by ilie t)v & igener^Se^

•Fi.3.   If ihe Disclosing Par^^

contractors^      thelyltatter Cjbrf i.fiQKtiQh^ eqiml ia

fbrni ahd substance tb those ui F^ L ii^,:K^»-.'ai^^^!idf.'^i^^tf wifli«>jit the prior \yrittehcpnsentof the Cityi use any so'ch contraetbr/su PJ.scJpsibg Parry h^

KQTB: If the Disclosing Party cannot certify      abbve, an,

explanatory statement must be attached to-this ED$i

CERTIFICATION

Underpenaltyof perju^y^

Ifiis: Ei?§ and Appendix. A (if applicab^      warrants that all

cei'tificatlons and statements

and complete as of the date furnished to the Gity.

The Wolcott Group Inc.

(Print pr type name of Disclosing^PjrWy)

By-:

(Sign here) ^

Vfclor Michel      

(Print or type name of person signing)

Treasurer of The Wolcotl Group Inc.

(Print or type title of person signing)

 

S

Signed and sworn to before me on (date) July 11.2014

Cook      County, ""nois      (state).

GxJ^ Notary Public.

"OFFICIAL SEAL" SHANNA Q. LOVE Notary Public. Slate of Illinois ' , My commission oxplros 10/28/17 ]

Page 12 of 13

Commission expires:

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED ClTY OFFICIALS;AND DEPARTMENT HEADS

ThisAppemlLx Is to be completed onjy by (a)wlilch.hns direct

ownership hatercst'iii the AppUcaufcexceedli^^      Is pottobe cohiplete'diby any legal entity

whrch lras only an indireeroWnership inte'J-est Inthe^AppH^

Undei;Murucipal Cod of any^ppUGaJ^

any elected city official or department head, A 'Tarmliarr^      if. aslpftlie date this EDS is

sigrtedY the Disclosing Pa^^

the mayor. any aldermah; the city clerk, the city tf^suje'r;o> an^

partner or as any pf theTolIovving> whether by blood or adppjipbi; pareii^ child, brother pf'sister, aunt or uncle, nieee of hephew, giw

or stepmother^ stepson or stepdaughter; stepbrother pr sjepsistef pr l^if4brother or half-sister

Applicable Party" means (1) ail e^ebutiv&'bfficers-tfj? ¥b!^&J[$C^sixis: ^-mrf^-ixstea jfi^b||0it|f.B4iai_? if the; DiscIosingParty is a cprpbratioujall partners bf the^ partnership; all general^

p'artjiersbip; al j managers, managing lneinberiaiid, jnemperS ^f^Pji§cto^jf4s the Disclosing Party is a

liniited lhibility company; (2) alLprincipal officers of theiDisclpsjrig Party; and (3^ ajry person hnvinjgTnore than

a 7.5.percent p\vnership interest.in the DiscipsingP^      tbepresidehi, chief

operating officer,, executive director,-chief finaft^      entity or any person

exercising similar authority.

Does the DiscIosingParty or any "Applicable Parry/' or anySpouse orDomestic Parmer thereof currently liave a "familial relationship" with an elected city official^:or departhient head?

[JYes [TJnIo

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

t rrv-5 1tp>-^-  b-e^^i^Mf^ L* ^ C

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is;

1. [] the Applicant

OR

1. ^ij> 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: "fid 6      e. L.(ji—      

OR »/

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

which the Disclosing Party holds a right of control:      

1. Business address of the Disclosing Party:     (_CQ> G Dv/**A<^. :^Jl, Surfc ti^Z      

1. Telephone: f>t>f )j2J?-S6$3   Fax: ($<f\) $»2.-^ H⁰ f   Email: R ch-SGk)r."Hf/tflH, uJVj
2. Name of contact person:      k      £ Q <vt"«**^vv-D
3. Federal Employer Identification No. (if you have one):            ...   - - ■--
4. 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):
5. Which City agency or department is requesting this EDS? fo^fr      

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

Specification ft      and Contract ft      

Ver. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1.   Indicate the nature of the Disclosing Party:

] Person      Limited liability company

] Publicly registered business corporation      [ ]      Limited liability partnership

] Privately held business corporation      [ ]      Joint venture

] Sole proprietorship      [ ]      Not-for-profit corporation

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

] Limited partnership      [ ] Yes      [ ] No

] Trust      [ ]      Other (please specify)

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

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

[ ] Yes      [ ] No      fi\ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title

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

Page 2 of 13

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

Name      Business Address      Percentage Interest in the

I      /      i      a P'?^cl°§.^mg Party ,

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[]Yes ,^No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (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

1. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the 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      bflNo      [ ] No person directly or indirectly owns 10% or more of the

Disclosing Party.

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

[ ] Yes      [ ] No

1. FURTHER CERTIFICATIONS

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

Page 4 of 13

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

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

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

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

Page 5 of 13

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

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

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

      \Lt      

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

ft/A-       ,             

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

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one) [ ] is p^isnot

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

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

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

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

PP*      

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[JYes ^No

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

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

Does the Matter involve a City Property Sale?

[]Yes      £3 No

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

Name      Business Address      Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

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

2.   The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee ofany 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 ofany 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

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes      Jfl No

If "Yes," answer the three questions below:

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

[ ] Yes      [ ] No

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

[]Yes []No

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

[ ] Yes      [ ] No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

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

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

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

The Disclosing Party represents and warrants that:

Page 11 of 13

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

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

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

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

CERTIFICATION

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

 

(Sign here)

dUg~&. <^c_r rA"Cu^r

(Print or type name of person signing)

frt$)&*~k-_} RJS <W

(Print or type title of person signing)

(Print or type name of Disclosing Party) By

tiiiw ui i/pv' nam** \jl puuun OlglllllgJ

*      D-ev/<LUpn*e*vf, tut

Signed and sworn to before me on (date)   T ("1

at      _ County,      i$ (state).

 

Notary Public.

Page 12 of 13

Comrnilssion expires. ^j/^/lQ

 

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

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

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

[ ]Yes

 

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

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

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [ ] the Applicant

OR

1. fa a legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthe

Applicant in which the Disclosing Party holds an interest: ~T~vO 6    VLtAt^lt. Leg—      

OR y

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

which the Disclosing Party holds a right of control:      

1. Business address of the Disclosing Party:

1. Telephone: 133*1)5 VI-frS* Fax: (f>]m)%l-^£m°(     Email:      £P krfrtf L>Y< • UTv*i
2. Name of contact person:   R.<      S^< Q^fox O
3. Federal Employer Identification No. (if you have one):             
4. 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):

wWc%^e}ci^ p(~ (T-hj's <fcc<yufl M^^y. (&r W'li/t-^e. Pu<L._;ckic*

1. Which City agency or department is requesting this EDS?       

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

Specification #      and Contract #      

Ver. 01-01-12

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

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

[ ] Yes      [ J No

[ ] Other (please specify)

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

[ ] Limited partnership

[] Trust [

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

 

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

□ Yes

[]No

pi N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1.   List below the full names and titles of all executive officers and all directors 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 of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name      Title       »      . .

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

Page 2 of 13

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

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 jKJNo

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf ofany 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

1. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

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

Disclosing Party.

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

[ ] Yes      [ ] No

1. FURTHER CERTIFICATIONS

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

Page 4 of 13

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

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

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

Page 5 of 13

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

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

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

UPr      

Page 6 of 13

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

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

>JA      

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

k)A      

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is      is not

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

1. If the Disclosing Party IS a financial instimtion, then the Disclosing Party pledges:

"We are 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 of the privilege of doing business with the City."

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

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

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

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

[ ] Yes      ^(] No

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

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

Does the Matter involve a City Property Sale?

[]Yes      Jtq No

1. If you checked "Yes" to Item D.l., 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 of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

 

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

U*r      

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

2.   The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member ofCongress, 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

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

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

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

[ ] Yes      [ ] No

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

[ ] Yes      [ ] No

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

[ ] Yes      [ ] No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

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

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

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

The Disclosing Party represents and warrants that:

Page 11 of 13

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

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

F.3    If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.1. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

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

CERTIFICATION

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

(Print or type name of Disclosing Party)

 

(Sign here)

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

Signed and sworn to before me on (date) ij i*^

at   CeC^-^      County,    [[( \ U_o t'5 (state).

 

Notary Public.

OFFICIAL SEAL CINDY J BELL NOTARY PUBUC - STATE OF ILLINOIS MY COMMISSION EXPIRES:08/18fl6

Page 12 of 13

Commission expires: ^//^<?r//C^

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

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

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

[ JYes

 

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [ ] the Applicant

OR

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

Applicant in which the Disclosing Party holds an interest:   | VO G~  ^Leck MC LLC—      

OR ZJ

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

which the Disclosing Party holds a right of control:      

1. Business address of the Disclosing Party:        (g(flG D V/ t\$j&£ fi Qc^Sl ₍ Qu'ik- l/O-^L
2. Telephone: ( Z^^ZI-^oSLFax: ( 4+))Si>      I    Email: AftO >'4 kQ fcv «\isluTy*. , _n
3. Name of contact person:   !D<frJ'<dt 3y PWT~      
4. Federal Employer Identification No. (if you have one):             

1. 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):

p-f^ulgor L^^}rlcr^\ op      Uj ^ ^.ca^J)     crvhj^yL^- f    ILeSu P<^U._f Citio^

1. Which City agency or department is requesting this EDS?    fo P f*)      

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

Specification #      and Contract #      

Ver. 01-01-12

Page 1 of 13

SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1.   Indicate the nature of the Disclosing Party:

[ ]      Person

[ ]      Publicly registered business corporation

Privately held business corporation

[ ]      Sole proprietorship

[ ]      General partnership

[ ]      Limited partnership

[]      Trust

[ ] Limited liability company

[ ] Limited liability partnership

[ ] Joint venture

[ ] Not-for-profit corporation

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

[ ] Yes      [ ] No

[ ] Other (please specify)

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

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

[]Yes      []No "JQN/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name

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

Page 2 of 13

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

Name      Business Address      Percentage Interest in the

Disclosing Party

t^lfl   fer.vt-    GOG   Dv»aJ^ RooJ_f S^\cilOZ   NM^UoA./L fOO^i

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?

 

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

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (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

A. 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?

[JYes

 

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

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

[ ] Yes      [ ] No

B. FURTHER CERTIFICATIONS

1.   Pursuant to Municipal Code Chapter 1-23, Article 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 ofthe City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

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

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

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

1. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
2. Neither the Disclosing Party nor any Affiliated Entity is listed on any ofthe 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.
3. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
4. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

MA       -      

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 ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe 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").

MA      

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

N/A      

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is      T^^{is not}

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

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

"We are not and will not become a predatory lender as defined in Chapter 2-32 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 ofthe Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

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

      HA      

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.

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

[ ] Yes I^S-No

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

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

Does the Matter involve a City Property Sale?

[ ] Yes f$No

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

Name      Business Address      Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

y\ pw-g—-      

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

2.   The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee ofCongress, or an employee of a member ofCongress, 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

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[]Yes

 

If "Yes," answer the three questions below:

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

[]No

[]Yes

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

[]No

[] Yes

3. 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:

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

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

1. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
2. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

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

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

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

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

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

The Disclosing Party represents and warrants that:

Page 11 of 13

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

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

F.3     If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.1. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

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

CERTIFICATION

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

(Print or type name of Disclosing Party)

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

Signed and sworn to before me on (date) __ __ _____

at f tr&\t--      County,      | (( fvio i *> (state).

Notary Public.

OFFICIAL SEAL CINDY J BELL NOTARY PUBUC - STATE Cf ILLINOIS MY COMMISSION EXPIREStiVieflS

Page 12 of 13

 

Commission expires:   ^/ fS~fl(^>

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

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

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

[ JYes

 

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION 1 -- GENERAL INFORMATION

1. Legal name qfthe Disclosing Party submitting this EDS. Include d/b/a7 if applicable: Ari H. Golson Revocable Trust dated August 20, 2004;

Check ONE- of the following three boxes:

Indicate' whether the Disclosing Party submitting this EDS is? 1. [ ]' the Applicant

²; M» ^a legal-entity holding a direct or indirect.interest in the Applicant. State the'leja^''tV^W*P'i'--iIih. Applicant in which the Djsolosing Patty holds an interest: twg Kedzie lie OR

.3,. •[] a legal entity with/a right of control (see" Section ILB.l.) State the Iggdlnanieof Ui^ ^ttijCy u<_; -

which the Disclosing Party holds a riglitof control:,       _

■       .       _fJ      , ,        ,  .      935'W. Chestnut, Suite 600

1. Business address of the Disclosing Party:

Chicago, Illinois 60642

_ _ ,        (312)226-2260             (312)225-8900      _ ari@wolcottgraupirjet

C. Telephone:      Fax: ____________      Email:      ; '-^? ^

Ari Golson

D-. Name of contact person.      

NonG

E. Federal Employer Identification No'(i£you have one):      

1. 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);

Applicant is seeking Ins City's approval for a re-subordlnatlon of tho City's Second Mortgage as part ol a refinance of Ihe First Mortgage

DPD

1. Which City agency or department is requesting this EDS?      

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

Specification //       and Conlract ft      

Ver. 01-01-12

Page I of 13

SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1.   Indicate the nature of the Disclosing Party:

[] Person      []      Limited liability company

[ ] Publicly registered-business corporation      [ ]      Limited liability partnership

[,] Privately held business corporation      [ ]      Joint venture

[ j, Sole proprietorship      \ ]      Not-fQr-prqfit corporation

[ ] Qeheraf partnership      (Is      the not-for-profit corporation also; a '5Q.j

[] Limited partnership      [ ] Yes      [ 1 NO

Q^Ttust      f]      Other (please specify)

ftir legal eht^      of incorporation t>rdrganu?atipii,- #$£11^*:'

M      

3.- For legal entities hot organized In the State of Illinois: Has the organization registered to do: business irt the State o f Illinois as a foreign entity?

[.Yes      [JNo f^N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1.  List below the full names afid titles. Of all executive officers and all directdr&of the. entity, NOTE: For nbf-for-profit corporations, also.list below all members, if any, Which are legal eri fi ties, 'If, there are no such members, write "no members." For trusts, estates or other similar entiU.es^iSfv^De^bw< the legal ti(leholder(s).

If the entiiy is a general partnership^ limited partnership, limited liability company, l.i'mited,ii1ability, partnership or joint venture; list below the name and title of each general partner, managing; member?, manager or any other person or entity that.controls the day-to-day management of the DisclosingJ?artj_. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title Ari-Gblson Trustee

2.   Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of lhe Disclosing Party. Examples of such an interesl include shares in a coiporation, 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 olher 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      Percenlage Interest in the

Disclosing Party

Ari.Golson      W. Chestnut. Suile.60O,-Chrcago.Hlinoisf 6D642      100%      

SECTION HIV- B USINESS RELATIONSHIPS WITH CITY ELECTED p;FPICIiili$:

Has lhe Disclosing Party had a "htisirxess relatfbriship_;," as defined in Chapter 2-1/5 § p/.the\M^fii^fea:t Code, with atiy City elected official in the 12 months before the date this EDS is sighed;?/

[ ] Yes "^No^

I f yeSj please identify below the name(*s) of such City elected officials) and desotibe^suoh. relationship(;s)t

SECTION IV - DISCLOSURE'OiF SUBCONTRACTORS AND OTHER RETAINED.PAJ^TIES:

The Disclosing Party must disclose the name and business address of eachsubcontractor, attorney^ lobbyist, accountant, consultant and any other person or entiiy whom the Disclosing Party has>refaine.d or expects to retain in connection With the Matter, as well as the nature ofthe 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 Parly's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative' action on behalf ofany person or entity other than: (1) a nol-fOr-profit entiiy, 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 Parly   Fees (indicate whether

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

to be retained)      lobbyist, etc;)      "hourly rate" or "t.bid;" is

not an acceptable response.

(Add sheets if necessary)

I Cheek here if the Disclosing Party has not retained, nor expects to retain, any such pefsbiis Or eutiti&sv

SECTION V CERTIFICATIONS.

A. COURT-ORDBRED CHILD SUPPORT COMPLIANCE

Under Municipal Codes Section 2^>2r415, substantial owners of business entities- tj^t4^^|--\V_;itb<-the City must remain in cojmpJiaitce with their j?hild support obligations throughout tiieconttactVtefttju

Has atry person who directly or indirectly owns 10% drmoreof tlie Disclosing Parity been d,ebl&ri$«t arrearage on any child support Obligations by any Illinois court of Competent jurisdiction?

[ ] YOs      \ijj\No.      [ ] No persOn directly or indirectly owns 10% or mare of Ihtv.

* Disclosmg-Party.

If "Yqs." has the person entered into a court;approved agreement for payment of all soppd'rLoWed and * is the person in compliance with that agreement?

t ] Yes

B. FURTHER CERTIFICATIONS

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

Page 4 of 13

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

1. arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unif of government;
2. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection wijJj: obtalniiig^attemptlng lo obtain, or performing a public (federal, state- or local) Iransaclidif or eoiUract under a public transactipn^a vl^latipri of federal or state antitrust statutes;' frtiud,;; embezzlement; theft; fbrgetyi'bribery,v falsification Or destruction, of records; making fjalse? StateiiiLents; or receiying/stblen property;

>q. fire ntftpresentlyttod'fpj(«4-f9r>-<it'^ritftHiftUyorpiviHyphased-by^^-g'Over^oierhtal'-eiit^

state: or 'lbp.H'l)--Si6i/co4riitn^,U'Uhjg any of the offenses set forth in. clause B'.2'.b: of this S^ebtieji-y;

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

e, have not, within, a frye-year period preceding the date of this EDS, been cpnYicted_r.a4judg'e<j gtfiltyi pr found liable in a.civiiprbpeeding, or in any criminal or civil, action, including actions concerning erivjponmental violations, instituted by the City or by the federal g'bvertraeht; any state, or anyOther-unit of local government

3.  The•Certificatibris."in subparts 3, 4 and 5 concern:

• the Disclosing Party;
• arry"*GOniraclor" (meaning'any contractor or subcontractor used by the DiscIosingParty in-connection with the Matter, including but not limited to all persons or legal entities disclose&hndep SectiqiifV, "Disclosure of Subcontractors and Other'Retained Parties");
• any " Affiliated Entity" (meahing a person or entity that, directly or indirectly: eontrpls the Disclosing Parly, is controlled by the DiscIosing Party, or is, With the Disclosing Party, linder. 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 entiiy 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 Affilialed Enlily means a person or entiiy that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
• any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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

1. bribed or attempted to bribe) orbeen 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 pr ofany state or Ibcal government in (he United States of America, in that officer's or employee's official capacity;
2. agreed or colluded with other-bidders or prospective bidders, or been a party to any.siteh agreement, OrJ.beerteonVicted or adjudged guilty of agreement-or collusion among; bidder$;6r; prospective bidders,In restraint of freedom of competition by agreement to bid a fixed pxfc&or 6therwise;'or

c- made ah admission of such conduct deseribed.ih a. of h. above that is a matter of record, btit have rtbfbeen "prosecuted for such conduct; or

d. Violated llie provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance);

Neither-the T^sclosih^Pafty, AffiltetMBntifyor Contractor, or any of their emplo^ee^^Q0ptaiSi. • agents or partners) f$ barred from contracting with any unit of state 6r.I6cal-$ov^rninen"tas.*.^s)<it_}0$' engaging in or being convicted of f I) 'bid-rig;ging irt violation of 720 ILCS 5/33E-3.; (2) bidrxblfttin^ ih violation of 720' ILCS 5/33E-4; or (3) any similar offense of any state or of the United S~iates-o;f America that contains the same elenienfs as theoffenSe of bid-rigging or bidrrofatihg.

1. Neither the DiscIosing Party nor any Affiliated Entity is listed on any of the following listfe maintained by the Office of Foreign. Assets Control ofthe U.S. Department of the Treasury Or the Bureau of Industry and'Security ofthe U.S. Department of Commerce or their successors: tlie&pe^itUly' Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the: Debarred List.
2. The Disclosing Party understands and shall comply with the applicable requirements of ChapteYS 2-55 (Legislative Inspector General), 2-50 (Inspector General) and 2-156 (Governmental Ethics} of the Municipal Code.
3. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

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

8,   To lhe 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-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 "hone"). None

9„  To thebest of the Disclosing Party's knowledge after reasonable inquiry, the followiftg is. a complete list of all gifts that the Disclosing Party has given or Caused to be given, at anytirnednrlngvrh^ li-nrqnth period preceding' the execrtripn date of this EDS, to an employee, or elected.or a pppjflfeil Official, of the City of Chicago Fox purposes of this- statement, a" "gift" does not inchide; 0) anything -made generally available to City ernploye.es or to the general public, .or (ii) food ordriuk.ptbVAtle'jfl iti tfrV course pf official City business and having a' retail value of less than $20 per recipient ;(iTnpne, $ggj§aT&» With ''N/A'* Or '-none"). As to any .gift listed. below^please also,list the name of the City recipient. Nona

C. CERTlFICA'FION OF STATUS AS FINANCIAL INSTITUTION

1 i  The Disclosing Party- certifies that the Disclosing Party (check one)

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

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

"We are not and Will not become a predatory lender as defined in Chapter 2-32 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 of the privilege of doing business with the City."

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

—N AfV -      

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 RJEGARJD1NQ INTEREST IN CITY BUSINESS

Any wdfds-or terms that are defined in Chapter 2-156 of the Municipal Code ha ve the same meanings when used lit this Part D,

L in accordance with Section 2-156-110 df the Municipal Code: DoeS aiiy official or employee, of fhei Oity haveafJaancialfinterest iii his or her own name or in the name ofany other per$,0fr'p/j entity in the Matter?

[jYes

NOTE: If you Checked "Yes" to.Item D.l., proceed, to Items D.2. and D,3. If you ehecked "No,¹' tp; heih DA., proceed to Part E.

2.   Unless sold pursuant to a proeess 6f competitive bidding, or Otherwise permitted, no City' elected. official Of employee shall have a financial interest in his or her own name orin thename' oT .any .other, person or entity in the purchase ofany property that (1) belongs to the City* or (ii)i$fS0.id for taxes or assessments, Or (iii) is sold;by virtue of legal process at the suit of the City (coilectiyely^, "City Property Sale"). Compensation for property taken pursuant to the City's eminent dbmainjppwW does not constimtea financial interestAVithinthe nieahing of this Part D.

Does the Matter involve a City Property Sale?-

[]Yes 0$o

3 If you checked "Yes" to Item D.I., provide lhe names and business addresses ofthe 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 thai no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

1- The Disclosing Party verifies that the Disclosing Party has searched any andall records'.of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the. slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death Of their sla ves),:aM the Disclosing Party lias found ho such records.

_j      2. The Disclosing Parly Verifies that, as a result of conducting ihe search in step I abov^.the-

DisblosingvParty lias found reeords of investments or profits from slavery or slaveholder inshrShce policies. The DisclosingParty-verifles that the following constitutes full disclosure of all subh records,,ihcluding the. nnm-es of any and allis]!av«s-SF.flay^ldQi<si desqribedaii those-reCjOrdsU

SECTION VI   CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: if the Matter is TedenUtyfu^cted,. complete this Section Vl If the Mattcf Is noi federally fuiidedi,pfpce.ed^: to SSetiori VlL Fpr purposes Of tfiis-Section VI, tax credits allocated by tlve'CUy and proceeds of debt obligations of .the. City are not federal funding.

-A. CERTIFICATION .REGARDING. LOBBYING

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

(If 110 explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be Conclusively presumed that the Disclosing Party means lhat NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2.   The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. 1. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee ofany agency, as defined by applicable federal law, a member ofCongress, an officer or employee ofCongress, 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

1. The Disclosing Parly will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A.l. and A.2. above.
2. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986;<ot (ii) it is an Organization described in section 501(c)(4) of the Internal Revenue Code of 19.86 but has not engaged and will hot engage in "Lobbying; Activities".
   1. if"the^:DiselpsI

form and substance to paragraphs iLL through A\,4.- above- from .all .subcontractors-before-it-aNV^cds any

subcontract and thQ>Disclqsing Party mxist maintainall'snch.si^      for the*

duration'of the Matter aM juristmake such certifications prompt Ly *a vailable. to the Gity upon _sre%jtte$h>

B. CERTIFICATION REG A RDING EQUAL EMPLOYMENT OPPORTUNITY

If they Matter is federally funded, fed,eraVreguiatiohs requite the Applicant and all proposed-subcontractors to submit the following"information with their bids or irt Writing at the outset Of negotiations,.

Ts (he DiscIosing Party the? Applicant?

 

[JYes

If''Yes,," answer the: three questions bjeloW:-

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See. 41CFR Part 60-20

[ ] Yes /j4No

1. Have you filed With the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under lhe applicable fiiingjxquirenients?

[]Yes [$No

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

[]Yes fJ^No

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

A. The certifications, disclosures,, and'acknowledgments contained in this EDS will become part.of any-

contract or other agreement between the Applicant and the City in connection with the Matter, whether

procurement, City assistance; or other City action, and are material inducements to the City¹* execution.;

of any contract of taking other action With -respect to the Matter. The Disclosing Party understands that

it miist comply with all statutes* ordin'anees>iihd,^      EDS is based.

%i The- C{^*f -j0.oy<^me.at)C|]:BtliXos ahd;.eamp$^      Chapters :2-i56 and2-164 of

the Municipal Code; impose certain d\U?es and obligations on.persons or entities seeking Gify contract^ wqrk, busirtess, or transactions, The full text'bf these ordinances and a training ^;pfo^mJS-«ya^l|ibi# joitt line at Www.Citvbfchicago.or^/Ethics^ and may also be obtained from the Gity!$. Bqard of EUucSi 740 %

Sedgwick St_ri Suite 500,; Chicago, It 6.0610, (3A2) 744-9660. The Disclosing Party must Comply fully with the applicable ordinances,

G. tf the City determines thiiifcany 'i'nfprmatipit prpvided in this BBS is false; incomplete or inaqpufate, any; contract or other agfeenisnt in qbhne;ction with which it is submitted may be fe;soiuded oirbe yoid.Ot voidable, and the. City may pursue ^y^m^es-Mfldjef'the. contract or sgreetn^ht^fflatfttesoiiidei^ vofd),.atiaw, or in equity, including ©rhtritra'tin^.thi? i^isclasing Party!s.p>rtjcjpaUpn in the Matter;aud/pf declining to allow the Disclosing Party lb pactfbipate: lb other ttansactTOhs with the City- Remediesiat law for a false statement of material fabt may include incarceration and an award to the City of treble-damages.

U. it is the City's policy to make this document available to the public on its Internet site and/or upon request. Some pr all of the information provided on this EDS and any attachments to this EDS may bp made available to the public ort lhe Internet, iit response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Parly 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 ofany information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Parly miist 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 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

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

F.2 if the Disclosing Party is the.Applicant, the Disclosing Party and its Affiliated Entities Will .hot'• . use, por permit iheiriubcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System. ("EPLS") maintained by the Li, S. General Services Administration.

E.3.    tf the Disclosing Party Is the Applicant, the Disclosing Party will obtain from' any

contractprs/subcontvactofs hired or to beihircd'in co^      equal'in

form and siibstahce}t6 thoSe. in F. 1,-.and F.2. abdveiari^ wilf not, without the prior written consent of the.

Cityi use'ahy.stich eplntracto^      that the

'D.ijsdto?itig^,$^faiffyAajt teafoh to believe lias nd^

NOTE: If the Disclosing Patty cannot certify as to any of the items in F.l.iF.2. Or F.3. above,-ah. explanatory statement niust. be attached to this EDS.

CERTIFICATION

Under penalty oTperjUrft theperson signing beTowi(.l) warrants that he/she is. authorised tp-eitephte, this EDS and-Appendix A(if.applicabIe)_;o

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.

An M. Cfflson Revocable Trust dated August it). 2Q04 (Ptyitwfer/e name of Disclosing Party)

(Sign here) Ari Golson

(Priul or type name of person signing) Trustee

(Print or type title of person signing)

C^Notary Public.

Commission expires

Signed and sworn to before me on (date) July 11. 2014

C^Cook^ounly      County, Illinois      (state).

"OFFICIAL SEAL" ^ SHANNA Q.LOVE i Notary Public, State ol Illinois /commission expires 10/28/17

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity wliicli.Jjas a direct ownershiplnterest in the. Applicant exceeding 7;S pertimt. I t Is not to be eoinpletcd:by any legal entity whlch hasonly an lncIh^et-p^ecslUp'ihfcr.c&tfti-'tlus AppUcaht

Under Municipal^

or ar$y ^AppjUeabl^ Party;' or any Spouse;-.pj? Pbme^ift Pafttier thereof tnrre        ^ ^iamilial Kl'ationshi^'- \vi|V>.

anyelected^;city official or department head. A "familial relationship'- exists if> as of the date this BDS_;i&

signed, the Disclosing Parry orany ^,vAgplic^      Partner mereof is. relnte4 to

the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic

partner of as any of the following, Whether by bloodpr adoption', parentj childi brother Of sister, aimfOr uncle,

niece or nephew, grandpafeh.t> grandchild, father-i^      s;on-i»-law, daughter-inJaw₊,stepfa.the!ii

or siepmpther-, stepson or stepdaughter, stepbrother or stepsister or hal£hrotheror half-sister,

"Applicable Paity'^AnVeans'(J^ all executive officers pf the DiscIosingParty listed in.Sectipn iLBJ.3_;y.ifthe

DisclositigPartyis a corporation; allpartner^ of tlie Disclosing Paity,;ifthe Diselosiiig Parly is a general

parthershipi aU generalpartners and liniiledipartners-of fto Diselos      Disclosing Party isaHmjterj.

partnership; all managers, pianagmg members andmembersofthe^istflosihg Party, ifthe Disctosing Party-is ar limited lability company; (2) all principal officers of the Disclosing Party; and'(3) any pei sonhaviug niOre;thah a 7.5 percent ownership interest in the Disclosing, Party,"Principal officers" means the president, chief operating officer, executive director, chief financial officer_y treasureror secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Parry or any "Applicable Parly" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with aii elected city official or departmenl head?

 

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 relalionship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I — GENERAL INFORMATION

A.      Legal name pf the Disclosing Party submitting-this EDS. Include d/b/a/ i f applicable:

Victor F. Michel be'claralipri of TrMSt.ddte^^P^tnbet'jl^Q^'

Check ONE of the following fhrcoboxcs:

Indicate whether the Disciosihg Party snbtiuttihj* this EDS is: I. [;]• the Applicant ' OR

2pMi a legal entity hbJduig a direct or Indirect interest in the Applicant State the legal aariie of tfte-

^Appiicant in whioh.thc.Disclosittg Party holds an interest: twg Kedzie i,lc      ■      .

OR

3, j: ] a legal enfityAvith a rightCJf opntVol (see Section II.B.l.) State the legal uaipeof the entiiy in

which the Disclosing Party holds a right^f control:;      

  .      935 W^Ches;tnat5lreel. Suite 600

B.      . Business address-'praterftisplqsirig Partyi    -       ,      :,

Chicago,'Illinois €0642

(312)226-2200           _w     (312)226-8900                    . Victor@wbieotlgrOup.net

C. Telephone:                  Fax;      Email:      -

Victor Michel

D. Name of contact person:      

None

E. Federal EmployerTdentiftcation No. (if you have one): _____

1. 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 properly, if applicable):

Applicanl is scojtlrig Uio Cilyfs approval Tor a re-subordlnatlon of Iho City's Second Mortgage as part ol a refinance ollho First Mortgago

DPD

1. Which City agency or department is requesting this EDS?      

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

Specification it      and Contract tt      

Ver. 01-01-12

Page 1 of 13

SECTION 11 -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1.   Indicate the nature ofthe Disclosing Party:

[ ] Person      [ ] Limited liability company

[ j Publicly registered businessicorporation      [ ] Limited liability partnership

[] PrLvateiy/ltefd'bflSiries^'dpfporatiprt-      [\ Joint venture

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

[ ] General partnership      (Is the riot-for-p'rqfit corporation also a SO 1 (c

M Limitedparfhership-      [JYes      [],No

] Trust      '[■'] Other (please specify)

2,  Far lejgal ^ntities_ tlie state (Or foreign; ^^_j^fin[qdipia8tip^i or organization, if applicable"?

IL

3.  For legal entities not organized in the State of-lllinois: Has the organization registered to do business in tliei?tate>ofIllinois asta foreign entity?

UYo>      []No p^I/A

B. IFTHE DISCLOSING PARTY IS A.LEOAL ENTITYt

I.  List below'the full names.andltitles of all 'executive officers arid all directors of the.en.tily. NOTE? For ho?-for-pfofit coiToratiops, also list below all members, if any, which are legal entities. If there are no such inembers, write "no members;*' For trusts, estates or other similar entities_s list below the legal titlehblder^S).

If lhe 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 perspn or entity thai controls-llie day-to-day,managem6nt of the Disclosing Parly, NOTE.' Each legal entily fisted below must sifbmit.an EDS on its own behalf.

Name Title Victor Miehel Trustee

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

Page 2.of 13

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

Name      Business Address      Percentage Interest in the

Disclosjng Party

yictor.Miche.l    935 W. Chestnut; Suite 60b. Chicago, IL 6Q642      100%      

SECTION XJI -t BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has. the Disclosing party had a."busiriess relationship,''as defined in. Chapter 2-15;6" of the Municipal Code,: with any City electedofjlclal in.Ihe_: 12 months before the date this EDS is signed?

1} Yes f%Y,m

 

If yes, please identifybelow me h'ain6(sj of such City elected 0f(icial(s).aod describe such relationship(s)r:

SECTION IV■* DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The DiscIosingParty must disclose, the naine and business address of each subcontractor, attorney, lobbyist, accountant, consultant artd-any other person or entity whom the Disclosing Party has.retained or expects to retain in connection with the Malter,aswell as the nature of the relationship, atid the total amount of flie fees paid or estimated, to' he-paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Parly'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 olher 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.

Ifthe 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:)

^jfc^eck here if the Disclosii^Party has not retamed;mbr expects to retain, any" such persons or entities.

SECTION V --CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal CodeSec&on 2*&Z?4 LS, s.abstanti^l bwiiefs of busmess.enU the City must remain in. compliance With their'child support obligations throughout the contract's term.

Mas: any. person who directly or indirectly owns 1,0%. or mora of the Disclosing.Party been declared in arrearage on any child support obligations by any Illinois court of competent jurjsdictiou?

flYes

 

[;] NO person directly, or indirectly owns 1.0% or more of the Disclosing Party.

If "Yes," has the person •entered into a court-approved agreement For payment of all support o^yed and.' is the person in compliance with that agreement?

 

[]Yes

B. FURTHER CERTIFICATIONS

1.   Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article l")(\vhich the Applicant should consult for defined terms (e.g., "doing business¹") and legal requirements), ifthe Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Parly 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 lhat compliance with Article I is a continuing requirement for doing business with the Cily. NOTE: Jf Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2.      The Disclosing Party ancL ifthe Disclosing Party is a legal entity, all of those persons or entities

dcntified in Section II.B.l. of this EDS:

1. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, stale or local unit of government;
2. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, of had a civiljudgment rendered against them in connection with: obtaining, attempting, to pbfaini or performing a public (federal, state or local) transaction or cbntract'tihder a public- transaction; a violation of federal or state antitrust statutes; fraud; embezzlement;theft; forgery; bribery; falsification 6r desfj-tictibn'of records; making.false, statements; of fe'ceiyihg stolen property;;
3. ape pot pjteseritly indicted'for, of criminally irviisnVtysfo (federal, State, or local); \vith conimtttirig .any:of the offenses set fof th in elauso B.i.b. of this Section. V;-'
4. have not, within' a fiVe.-year period precediiig tlte date of this ED$, had one or more public transactions (federalj.state or local) terminated for cause Or default; and
5. .have not> within a five-year period preceding-the date of/this- EDS,.been convicted, adjudged

guilty, or Found liable ln a civil pco'eeediug, ot in any criminal or-civil action, including actions

concerning en      City or by fbefedefal government, any

state, or any other unit of lOeal^goyernmerU,

3.      : The certificationsi iff subparts 3, 4 and 5 concern;

• the Disclosing Party;

? any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection wilh 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 of indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, wilh the Disclosing Parly, under common control of another person or entiiy. 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 wilh federal or state or local government, including the City, using substantially the same management, ownershipi or principals as the ineligible entity); wilh 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 entiiy;
• any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Enlity or 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 ofthe Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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

1. bribed or attempted to bribe* or been convicted bradjudged guilty of bribery or attempting.to bribe, a public Officer or employee of the City, the. Stale of Illinois^ or any agency of tlte federal government of ofany statepr local government in the United States of America, in that officer's pr employee's, official capacity;.
2. agreed of colluded with_: ptlief bidders Qt' prpsp^.ctiv^btddefs; or been a party to any such

agreement, or bfi&n CQrtvicted> or alt^dged^giiilty of agreement or cdjlusiojv amongibidders'Oir

prospepttve bidil^fSi in restraint of freedom      by agreement tp bid a f&ed price. ot

Otherwise;, or

e. niade ah admission of such conduct described iri. a. ot b. above that is a matter ofrepordr hut have hot been pfbsecufed for such condupfvP^

d. violated fhepfoyisionsof Municipal QLtf#&&G$j>ii'2^2i*6 l^-0 (Iwiying Wage Ordinance),

A. Neither the Djselosmg Party,. Affll iatett Entity Of<dbntractpr, bx arty of their employees, officials, agents of partners, is barfe.d from contracting w ith-anyunit of strfte or local government as a. result of engagingid.or being cpijYictcd of (l>bid^lggihg in violation of 720ILCS 5/33 E^3; (2) bid-rdtatilig in Violation 6f72Q ILCS 5/33E-4; of (3) any siihiia^ pffense ofany-state or of the United States of A merica that contains the same elements as thei Offense Of bid-rigging or bid-rotating:

1. Neither the DiscIosingParty nor any Affiliated Entiiy is listed on any ofthe 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 Comnierce or their successors: the Specially -Designated Nationals List, the Denied Persons List, theUnverified^List, the Entity List and the Debarred List.
2. The Disclosing Party understands and shall cOhiply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
3. 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:

Page 6 of 13

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

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

Sf. To thebes/tof thiDisclpsin^ P^tty^ kno>v1ed^

coiuplete listof al^ given.atany-tlm^^

12-rbonth berio;dVfirebe4nl£^      ED$, to aireniploye.e^pr elected; of appointed

of ficial; of the City of Chicago, por purposes0f this statement, a "gift" does not include: (i)ariything

made generally available td City employees Or to the general publicsor (ii) food prdrinle provided in tlu>

bourse of official City business arid having a, retail¹ vaUie pf less than $20.per recipient (ifnpne-, indicate

with "N/A" or "none/0¹ As to-any gift listed beldw, please also list the naine of the City recipient. None

C. CMTIFICATfON. OP STATUS AS FINANCIAL iNSTiTUTION

1. The Disclosing Party certifies that the-Disclosing Party {check*one) i) is r^^isnot.

a "financial institution¹' as defined in Section 2-32*455(b) ofthe Municipal Code.

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

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We furtherpledge 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."

Ifthe 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 ofthe Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13

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

D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any Words or terms that are defuied ih Chapter 2*156 of the Mithicipal Code have the same iheanihgs when used in tliisPart Eh

i.  In accordance with Section-2n 1.56-\ l.Q of the, MhhifiipaiCOdei DbCaatty official or employee Ofthe City have a financial intorestih his oriier own Jtaine Or. in the haute of tiny other person Or entity u>'the Matter?

[ ] Ye s      f^ N p

NOTE; If you checked "Yes" to Item■■.0.1., proceed.to Items D.2ahd,D.3. tf you checked ''Np" to Item D, 1„ proceed to Part E>

2;  Unless sold pursuant to a process of^piiip$ti|ly^^d4>n||U'Of otherwise perhiitted,JiO;City elected official Or employeessnail have a financial inteYeStin; his other own name or in the name of any other person or entity in tire purchase: of any property that (i) b'eippgs tb the;City, or (ii) is sold for taxes or assessments; or (iii) is sold by virtue of legal, prbcess at thpsuif of the City (aollectivcly, "City Property Sale"), Cpntpensation for property taken p'ufsuent'to tlte City's eminent domain power does no t constitute, a financial interest w ithin the meaning of this Part D.

Does the Matter involve a City Property Sale?

[JYes

 

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

Name      Business Address      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.

I J\ 1. The Disclosing Party verifies that the Disclosing Party has searched.any and all records of t(\e Disclosing Party and any and ail predecessor entities regarding records of investments or profits, from slavery or slaveholder insurance;policies, during; the slavery era .(including insurance policies issued to slaveholders that provided'coverage, for damage to or injury or death of their slaves), and the D isclosing, Party has found rib such records.

      JZ. The Disclosing Party verifies that, as a fesuitiof b.oh.duc.thig the search in step 1 above, the

Disclosing Party has found records of. m,vesuiiehts,^;of profiis ftbni slavery or slaveholder insurance

policies. The Disclosing Party verifies that the follO.\viugcoristiiates full disclosure ofall such,

records,.iM|idt^ljte:n»it^S^f^M^and fcttisteves 6^^      in those records;.

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter Is federally funded^ coihplete this Section VI. if the Matter is not federally funded, proceed to Section VII. For purposes of this Section VT, tax credits allocated by the City and proceeds of debt obligations ofthe (Giry are not federalifundihg.,

A> -certification rega rding lobbying.

1.  List below the names ofall persons, of entities registered under the federal Lobbying Disclosure Act ofl995 who have made lobbying contacts-on behalf of lhe Disclosmg Party with respect to the Matter; (Add sheets if necessary):-

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

2.   The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee ofany agency, as defined by applicable federal law, a member ofCongress, an officer or employee ofCongress, or an employee of a member of Congress, in connection with the award ofany 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

1. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A.l, and A-2. above.
2. The Disclosing Party certifies that either: (i) it is not an organization, described in section 501(c)(4) ofthe Internal Revenue Code of J 986; or (ii). it is an organization described in section 501(c)(4) of the uiteriial Revenue Code, of 1986 but has not engaged and will not engage in "Lobbying Activities".
3. Ifthe Disclosing Party is^heApplicartt, the Disclosing Party must obtain, certifications equal in

form and substance to. paragraphs A, U through AA above from all subcontractors before it awards any

subcontract, and-the disclosingParty nn«st'maintam gli. such snbjEphtrac.tors' .certifications for the

duration of the.'Matter and. must make suchpOTtifie^      City upon request.

B. CERTIFICATION REGARDING EQUAL BMP LO YMENT'O PPO RTUNIT Y

If the Matterls federally funded, federal r^gulations reqinre the. Applicant and all proposed subcontractors to-submit the following irtforhiatipp with IheirbidS'of in writing/at the outset of negotiations.

Is the Djsclosing Party the Applicant?/

□ Yes QfcNo If "Yes," answer the three questions, belpw:

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

[]Yes rtajo

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

[]Yes Htalo

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

[ ] Yes fTNe^.

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

Page 10 of 13

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

The Disclosing Party understands and agrees that:

A.      The certifications',-disclosures, and pcknowledgments'contaiiied in this'EDS will become part ofany

conttacf or other agreement between the Applicant and the City in connection with the Matter, whether,

procurement, City assistance, of other-City action, and are material.inducements to the City's execution

of airy contracton taking other action with respect to the Matter. The Disclosing Parly understands that

it must complywith ail statutes, ordinances, and regulations an Which, this EDS is based.

B,      The City's Governmental Ethics and Campaign FinancingOfdihaftces, Chapters 2-456and 2-164 of

lhe Municipal Code, impose certain duties and obligations Oft persons or .entities seeking City contracts,

VfQTk, business, or transactions; The-fiiUvtextbf'thege prdihartces<a^      is available on

line at w ww.cilvofchicagQvOrg/Ethics, and mayatsp.be obtained; FfonKthe City's.'Board Of Ethics, 740

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

C; If the City-detei-rnines that anyiufonnation provided in this, EPS- is false, incomplete or inaccurate^ any contract or other agreement (in <;onne;cdonrwith:\yhieh ijt is. submitted may be; rescinded or be void or yoidable^attd fhe; City inay. pursue any remedies under the contract or agreement (if not rescinded or void), at layv, or in erjuityj includlhg terrninating rtiePiselosihg PartyVpafticipation in the Matter and/or declining to allow the.Disclosing Party to partici^ate.-ih pfher transactions with the City. Remedies at law for a false statement of material fact may include incarceration; and an award to the City of treble damages.

D.      It is the City's policy to make this document available to the publje wits Internet site and/or upon,

request. Some or all of the information prpvjded on this EDS and any attachments to this EDS may, be

made available to the public oil 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 ft may have against the.City in connection with the public release of information

contained in this EDS and also authorizes the City to verify theaccuracy of any information submitted

in this EDS.

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

Party must supplement this EDS up to the time the 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 conlract requires. NOTE: With respect to Matters subject to Article 1 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 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Party represents and warrants that:

Page 1 I of 13

F.1.    The Disclosing Party is not delinquent in the payment of aiiy tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any firie^ 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    Ifthe DiscIosingParty is the Applicant, the DisclosingParty and its Affiliated Entitieswill.nol use, nor permit their subcontractor to* use, any facility listedby the U.S;.E;.p.A>.outbe federal Excluded Parties List System C"EPL$") maintained by the U. S. Qeneral Services Administration,

F.3    If the. Disclosing Paity Is the Applicant, the Disclosing Patty will obtain from any

contractors/subcontraetora hifcil or to be hired in connection with the Matter certifications equal in

form and substance to those in F.l-. ahd ^

City, use-any such contractor/subcontractor tha$ dbe&npt pip^^

Disclosing Party has reason to believe has iiot pf^

NOTE: Ifthe Disclosing Party cannot certify as to any of fheit^msinF.t.j E.2, Of^:F.3^;. above, an explanatory statement must be attached' to this EDS.,

CERTIFICATION

tinder penalty of perjury^ the person signing belO\y; (X) warrants tbnt lie/she is authorized to execute •this EDS . and Appendix-A (if applicable) pn .behaif Of the Disclosing Patty¹, .and (2) Warrants that all certifications and stateinenife contained in this EDS and Appendix A (if applicable) are true_y accurate and complete as of fhe.datefurhished'to the City.

Victor F. Michel Declaration of Trust Ualetl Seplanlher 13^2004 (Print of type name of Disclosing Pa^fy) /

By: L^^C^^Ip^

(Sign here)

Victor Michel

(Print or type name of person signing) Trustee

(Print or type title of person signing)

Notary Public.

 

Signed and sworn to before me on (date) July 11.2014

ok County      County^Illinois^—       (state):

 

Commission expires:

SHANNA Q.LOVE >ry Public. State otfcote ommlasion nxplres10J2Bnrj

Page 12 of 13

CITY OF CHICAGO ECONOMiC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

Tlili Appendix is to be completed only, by (a) the Applicant, rind (b) any legal entity which lias a direct

ownership interest In the Applicant exce^      It knot to. be epmplcted:by any legaLenfity

which has only an ihdu'ecf bwhership interest in the Applicant.

Under Municipal Cod^ Sectipn. 2-1^015* the Disclosing Parfy must disclose whether such Disclosing Party

or any* Applicable Party" or any Sppuseor Domestic P^tner tliercOf currently has a "familial relationship^ whh

any elected city official or department head, A'TahWi^'r^      ET3S is

signed,, the Disclosing Parly or any applicable. Party 'of any Spouse,or Domestic Partner thereof is related to

tbe maypr, any alderman, the city clerk, the ci^neasnrer br any cjty.d'eparjiment head as spquseor domestic

partner or as any oflhe.fplltavjj^      Or adoption: paretic child* brother or sister, aunt or uncle,

nieceor nephew, grandparent,.grahdehild, falher-iitilavv, mpther-irt'laWj sdn-dn-law, daughter-in-law, stepfather, of stepmother, stepson of stepdaughter, stepbrother or stepsister ox half-brother or half-sister.

"Applicable Party" means (:1) alF^ ifthe Dis,clbsirtg Party is a corporation

partnership; all general partnersand timiteb^partfiexs of the DisblpsmgParty^ ifthe'DiscIpsing Party is a limited: partnership; all managers, managing memher^and members pf the DiSelosingParty, if the BfeclosmgParty isa limited 1 lability cbnjpanyi (-2) all pflnoipal offi^^r^ pf the Pi^ljbsiing'Party; ^:&ad (3).n»y- persofn having mor& than a 7,5 percent ownership interest in the Disclosing Party. ^,TrmbipaI oflic.ei'S?^,nie'ans (he president,-chief operating officer^ executive director, chief financial officer, treasurer or secretaiy of a. legal entity orarjly person exercising similar authority.

Does ihe Disclosing Party or any "Applicable Pafty'' or any Spouse or Domestic Partnef.thcreof currently have a "familial relationship'' with an elected city official or departmenthead?

 

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

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

A. Legal name of the Disclosing Patty submitting this EDS. include d/b/a/ if applicable: Andrew S. Goodman Rovpcable Trust dated January 15; {200?

Check ONE of the following.three boxes:

Indicate whether the Disclosing Patty.si'ibnlibing this EDS;is:: l . '[ ]- the Applicant

OR      , ,

arife^xa. legal entity holding, a .direct or indirect interest in the Applicant, State the legalianieofth&

VApplIcant in Which the Disclosing Party holdsah interest:, twg Kedzie Lie-       ■

OR

3* [3 a legal entity with a tight of control .(see Section fI.B.l .) State the legalname pf the-e'iifityln

Which the Disclosing Party-holds ii right of control:     ._: .      _;      .

935 W. Chestnut, Suite 600

B. Business address of the Disclosing Party:       ;            

Chicago, lllihgis 60642'

(312)226-2200      (312)226-8500      . aridy@WolcdtlQrdup.n6t

C: Telephone: _.      Fax:      '      Email:      ■        ^{a F}

Andrew Goodman

1. Name of contact person:      

None

1. Federal Employer Identification "No. (if you have one):           ,      _s      
2. Brief description of contract, transaction or other undertaking (referred to below asllie.-M atf.er^)'(0-which this EDS pertains, (Include project number and location of property, if applicable):'

Applicant fo seeking ilto Cjl/s approval lor a re-cuborfinaUon of tno City's Second Mortgago as part of a refinance ol tha First Mortgage

DPD

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

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

Specification U      and Contract #      

Ver. 01-0I-I2

Page I of 13

SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1.   Indicate the nature of the Disclosing Party:

[ J Person      [] Limited liability company

[ .] Publicly registered business corporation      [ ] Limited liability partnership

[ ] Privately held business corporation      [ ] Joint Venture

[] Sole proprietorship      [ ] Npt-forrpfofit corporation

[)• General partoership      (Is the not-for-profit corporatiptf. aJsbi 4 4ffljfejf_rM^

[ ] Limited partnership      [] Yes      [•] Np

ffiist      [ ] Other (please specify)

2.  For legal entities, the state (or foreign cobhtfy) of ijibo.rporatibn Or o^ftfi^fibtt}.$f^|j^Ii^|i^'

N/A

-3. 'For legal .entities not organized in the Stale Of Illinois: Has the organization registered .to df> business in the State of IlUtiois as a foreign entity!?

.T3Yes      [jNo Q^/A

B> IE THE DISCLOSING PARTYTS A LEGAL ENTITY:

L . Liist.hclbw the full rfaineS and titles of all executive officers and al^.4ure;£tMs<>flh.^^»uS^ NOTE: For not-for-profit corporations, also list below all members, if any, which ar^Iegal et^es; If there are no such members, write "no members." For trusts, estates or other similar eptitieSj list below the legal titleholder(s).

Ifthe entity is a general partnership, limited partnership, luniled liability compaby, limite'd liability partnership or jouit venture, list below the name and title of each general partner, managing-ittcriibef, manager or any other person or enlity that controls Ihe day-to-day management of,the DiscIoSihg-Paliy. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title Andrew Goodman Trustee

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

Page 2 of 13

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

Disclosing Party

Andrew Gpodman        905 W- Chestnut; Suife §00. Chicago, (L 60642 100%

SECTION IH>~ BUSINESS RELATIONSHIPS WITH CITY ELECTED OFElQIALS

Hasthe Disclosing Parly had      as defhied in Chapr£j.'2^wJ^

Co.dei With any City elected, official in the 12: monllis before lhe date this EDS is signed?

 

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcpnfrafilpr, attorney, lobbyist, accountant, consultant and. any other person or entiiy whom the Disclosing'party has.retaiheid.i-or expects to retain in connection with the. Matter, as well as the nature Ofthe reIatioiis.hip_|l^hd.tlie^: total afnmfht ofthe fees paid or estimated to be paid. The Disclosing Parly is hot required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or enlity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a notrfor-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity auy part of whose duties as art employee of another includes undertaking to influence any legislative or administrative action.

Ifthe Disclosing Party is uncertain whether a disclosure is required under this Section, lhe 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)

ij^TCbecKhere if' the^isclosing Party has riot retained, nor expects tpfetaiavafiy'su^'pjsr^bYi^jvishtitiejif. SECTION V — CERTIFICATIONS A- .CO"MRt^ORDEP>ED CHILD S UPPORT COMPLIANCE:

UnderMunicipai Code Seotion. 2*92-41.5, substantial,owners o the'Glity must fem.ain in compliance with their child Support obligations throughout the'-.cohira^sfe.ftft'

Has any person who directly ox indirectly owns 10% or more of die Disclosing Party tteen d^^MJi^i arrearage oil any child, support obligations; by -any Illinois court of competent jurisdibtioh?'

DYes

 

'[ J'No person directly or indirectly owb&l:Q%'-OF'hi.p^^tirfr''' Disclosing party.

If "Yes,V lias the-persdn entered iii to a ^:cpurt-approyed agreement for payment 'pfM.^ttp^itioj^e^Vihd:-is the person In compliance with that agreement?

 

[JYes

B. FURTHER CERTIFICATIONS

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

Page 4 of 13

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

1. 1. are not presently debarred,, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;.
   2. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged .guilty, or had a civil judgment rendered against them in■co.nnee^lpflAylth;: obtaining, attempting to obtain, or. perforiping a public (federal, state or. local) ttanS.actmn<pf^; contract under a public transaction; a: violation of federaLor state. antfu^$t:-s^.tu4e^>_i^:£r9!4dh jepibezzlemtent;. theft; forgery^briberyi,.fa|.sificatibn ordestnietioh b^-reccjft^^^a^a^^j^r¹ statements; or receiving stplen .property;
2. are nbt presently ind&ted i^

state or     1) AVijli cottiiuiftixig nhy <?f the offenses set forth ft.plauSe-&$jr.pf^^ffim^? *

1. have not, Within a five-year period preceding the date of this EDS, had ohe or more" public fransactlojffS'(federal, state or. local)-temnhated for cause or default; and

e; haye Mtj within a fiv0-^

guilty:, or fpund liab'le in a civil proceeding. Of iri.any-Criminal of ciyU acttott, in^iv»y^i^iTQiipjjts> •fcdftfce'ffrtn'g. ^i'rQ'nm^^il violations, instituted by tlte .City of bythexfede^3l;g^^^ state, or. flny-btlier unit of local,government.

.3.  The Certifications ih subparts 3_a 4-and 5 concern.'.

• the Disclosing Party;
• any ^,iContraetor'^>'(hieaning any contractor or subcontractor used by fhe.Disclosihg Party id connection With the'Matter, including but not limited to all persons or legal entities dis'closejd tiudef Section IV, "Disclosure of Subcontractors and Other Retained Parties");

•■any "Affiliated Entity" (meaning a person or entity that,.directly or indirectly: controls tire Disclosing Parly, is controlled by the Disclosing Party, Or is, with the Disclosing Party* Under; common control of another person or entity. Indicia of control include, without limitation; interlocking management or Ownership; identity of interests among family members, shared facilities, and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government^ including the City, using substantially the same management, ownership,, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entiiy;

• any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant lo the direction or authorization of a responsible official ofthe DiscIosingParty, any Contractor or any Affilialed Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Enlity of either the Disclosing Party or any Conlraclor nor any Agents have, during lhe five years before the dale this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's conlract or engagement in connection Avith ihe Matter;

•a.   bribed or attempted to bribe, or been convicted or adjudgesd guilty of bribery of attempting to; • bribe, a public officer or employee of the City, the State of I llinois, Or any agency Of the federal government of of apy statepf local government in the United Stet'e$ -pf Am^ric^_i::i^.tKait|%Cej^ d^emp[pyce^f5 official capacity;

1. -sjsreedrorcojiiicled Willi^- o.thVb«W.eJ& pr-pro,speic;tiv$ bidders, or been a party to auy .^oii;¹ •
2. agreement, or been convicted or adjudged gujltyvof agreeipejit tfr OQllustoi^^^j^.lilil^i^gap
3. prospective      by agteeiWeUti0:bid4%xi?^r^W^;'

Oth.er\Vise; or

1. oiadeart admission of such.conduOt described in a> or b. above that is a riiatter of f^bbf^^ bnt . havs not beeh.pr0secuteblfor sucWonductj of
2. violated; the provisions of Municipal Code Section 2*92-610 (Living Wage Ofdiu&XQej).

1. Neitherthe Disclosing Party;, Affiliated Entity of Contractor, pr any of theirmn^l^^Mp^i^ agents or partners, is barred from conUticting with", any unit of state or local govefriment'.^^ ejigagingih or being convicted Of (1) bidr.rigging in violation of 720 ILCS S/SJEtSi^j'-^^^tatia'^^:it^ violation of 720 ILCS 5/33E-^lbr.(3)any Siinilar Offense of any stateor of the United St^feipf America that contains the same! elements as'tlie offense of bid-rigging or bid-rotating;.
2. Neither.the Disclosing Party nor any Affiliated Entity is listed on any of the followingl^stg maintained by the Office of Foreign Assets Control ofthe U.S. Department of the T,tea$uf;y'pr the Bureau pflndusliy arid Security ofthe U.S. Department of Commerce of their^- successors; the Specially Designated Nationals List, tlte Denied. PersonsList, the Unverified List, (he Entity List and the Debarred List.
3. The Disclosing Parly understands and shall comply with the applicable requirements of .Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe Municipal Code.
4. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

j^J^I      

Page 6 of 13

Jf (lie letters "NA," the Word "None," or no response appears on the lines above, it will be conclusively¹ 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 ofall current employees of the iDisclosing Party who were, at any limedufing the; '12-?

month period preceding the execution date of this EDS, an employee, or elected Or appointed official,

Of'Ihe City of Ghicago (if none; indicate, with -WA" or "none"). None

:9? To the best of the Disclosiiig Party's knowledge after reasonable ihqnify, •flieTdflowing fta: Cbmpletelistofalfgifts that. theiDisOiosiiig Party has given or caused to be?.givert_t fife af^ii^4^t^lM I:2-ri)pnfh period'preceding the bxeOutioh date of this EDSi.to an-employee* or elected oHp;r)pit\te4 official, of the City of Ghicago., For purposes Of this statement, a "gift" does not inGlude;.^^^ made generally available to iCity employees or to the general public, or (ii) food oi drink providedIn^d Courseof official City business and having a retail value of less than $20 p& recipient (if'ridhis, innate Wilh "N/A" or "none''). As to any-gift listed below, please also list the name of lhe City reciptehL None

C. CERTIFICATION OF STATUS AS-FINANCIAL INSTITUTION

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

[]is r-j^not

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

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

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

Ifthe 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):

nj (ffy      

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. CERTIFICATIQN REGARDING INTEREST IN CITY BUSINESS

Any words or terms'that aredefined in 0iapter 2-156 of the Municipal Code have tlleiSanTs-meanrngs whch used in this Part D.

1,      In accordance with Scetibn 2.-i56*UQ b,f the Municipal Code: Does any official .bf^etltployee

Of^he City have a fbiahcia(^;ih(erest in his drhSr own name or in the. name of any otheir petspp ctr

entity in the Matter?^:

I '} Yes j^fNo

NOTE; ;ifydu;checked: ''Yes?' to It.eftj, D.l .yprocee'd toJtems D.2. and D.3, Tf you ehe:cked^,fNjri'^?-tp Item D.1,, proceed t p. Par t B.

2.      Unless sold pursuant to a process of competitive bidding, or otherwise permltted,.nb<3jty

elected.official or employee shall have a financial interest in. his or lief- own name Of in the htfmerOf

any Othe? person ;or entity in the ptftehase of nnyproperty that (i). belongs to the- CHy^or'(iQ i^l^i

ibittaxos or assessments, pr (jii) is sold by virtue of legal process at the suit of ^^fheCity.(cbife0h^ejy"_i,

"Crty-Properly Sale"). Condensation for property taken.piirsuanl to the City's «.nline.nf'°ddma$i jfcfteft

does nbt constitute a financial intereSst within the meaning of this-Part D .

Does the Matter involve a City Property Sale?

 

I l Yes

3. If yOn 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

<a (fi*      -      

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

The Disclosing Party verifies that the Disclosing Party has searched any and all records of losing Party and any and all predecessor entities regarding records of investments, pr profits from slavery or slaveholder insurance policies during the slavery era (inclnding insvjtraiice policies' issued to slaveholders that provided coverage for damage to or injury or death of their slaves), ah(i the Disclosing Party has fpiind lib such records.

      2. The Disclosing. Party verifies that, .as a result at conducling the search in step I 'abOve* lhe

Disclosing Party h^s fpibid records of hiveslmehts brpjofjlsfroni slavery or slaveholder iasur/ttipe: policies.;. The Disclosing Party verifies thaTthe following constitutes full disclosure of all such records,, including the names gif any audiairrslavea or slaveholders described iiv those repOrds>

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE; Ifthe Matter is federally funded, complete this Section VI. Ifthe Matter k rtotfedctfalfy funded, proceed fp Section VII; For purposes of this Section VI; tax credits allocated bythe.CitjC-and prbceeds of debt obligations of the City are hot federal funding.

A. CERTIFICATION REGARDING LOBBYING

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

- a (V      :—:      

(If no explanation appears or begins on the lines above, or ifthe letters "NA" or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Party means lhat NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Parly 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 ofany agency, as defined by applicable federal law, a member ofCongress, ari officer or employee ofCongress, or an employee of a member ofCongress, in connection with Ihe award ofany federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or lo extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

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

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

5* if theplsclosing Party is the Applicant), the Disclosing Party must obtain cerlificatidnS' eqUal in form and subsfance. to paragraphs Ajly through A.4. above;ftoin''-aU-stibcoiitwotdrs' beforeit^vardsiaoy¹ subcontract

duration of the M alter arid mus.tmtfke .suchcertificafion&promptiy available to the City. up"oivr4qi^Sti>

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

If the Matter is federalty funded, federal regul'ftfipns tequire the Applicant and all proposed ' s_;ubcpntractotS: tp siibhlit the following iufbrntarfotv \vith. their bids or liv writing, at; the outset of. negotiations.

Is the Disclosing Party .flie.Applicanl?

flYes r^No If "Yes," answer the three questions belo.wt-

1. :MaVeyou developed and do, you have pn file affirmative action programs pursuant to applicable, federal regulations? (See 41 CFR Part 6Q-2.)

[ ] Yes [JNo

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

[]Yes []No

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

[ ] Yes      [ ] No

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

Page 10 of 13

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

The Disclosing Party understands, and agrees.thai:

At The certifications, disclosures, and acknowledgments contained in this ED'S wiiLbe'come.part'of any contract or other agreement between the Applicant and the City hi connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Patty understands ,tbat it must comply -Wi.th. all statutes, ordinaitpes, and regulations on'which this EDS is based.

B. The City's Gov.ernjnentai Ethics and Campaign Finanomg.prdiriauces, Chapters 2-ISbaiid ^lp'^of thb Municipal. <5odCj,impos:e certain dut

Ayorki business, or transactions The full text Of the'sb, ordinances and a- training.p/ogromi«^a^l>^^ line at WWW:cityofchicafi0.org/Ethics. and may also be optai'ued .from the City's Board of Ethics, ,74fr

Sedgwick St„ Suite SpQv ChiCagp, IL 60.61.0, (312).744*9660. The Disclosing Party.nuist.comply fuljy, with the applicable ordinances.

C_r If the City determinps that apy informati   provided hvthis EDS is false; incomplete or inaccjufgte,

any 'contract btqther agteemept in connection With which it is submitted may be rescindedidr be Void 6jK

vpidablpi and the; Pity may pursue any ren'iedles unttef the conlract or agreement (if not rescinded or

void), at buy, pf in equity, iuehicfing.tfi^^^      participation in the Matter ahd/bc

dee lining to allow the Disclosing Party to participate in other transactions with the City. RenVexlh&fC law for a false statement pf material faefirtay include-.incarceration and an award to the- Cify^!of treble damages.

1. . It is the City's policy to make this document available to the public on its Internet site artd/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, of otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights of 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 ofany information submitted in this EDS.
2. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Parly must supplement this EDS up to the time the City takes action on the Matter, Ifthe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 Of Chapter 1-23 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 1-23 and Section 2-1 54-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

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F. I.    The Disclosing Party is not delinquent in the payment ofany tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its A ffiliated Entities delinquent, iivpaying.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 (axes.

F.2    IF the Disclosing Parly is the- Applicant, the Disclosing Party and its Affiliated Entities, will jiot use, nor permit their subcontractors, to-u.se, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("BPLS") maintained by the U. S. General Services Administration.

F,3.    if the. DiscIosing Party ls the Appli.cant,: the Disclosing Party will obtain from any

cpntractois/subeoftttst^jo^ lifced.pt' td■jfeMfsji'ld. cpiineption with the Matter Gert'ificafions etjLual tft:

form and.substance to thosife in F.1, and F;& above and wilthpt, without the prior written jcoftsbrit bHie

City, use any suco.cp;ntfaeior^^^      thatdpesnotproVide such certifications or that the

Disclosing Party has reason to believe ixas no;tpf byided or OnrinOt provide truthful c;eitiftoati.oh&

NOTE- IP the. Disclosing Party cannot certify afc,fb any of the items mF.L, F.2. or F.3... above-, aiv explanatory statement riiust be attached to this EDSv ,

CERTIFICATION

Under penalty of perjury,, the person signing ibclpwr (1) warrants that he/she is authorized tp execute

tins BfiS and Appe^^      Party, and (2) warranty thai all

5erfifiCafip.ps.a1id statements, contained in this EDS and Appendix A (if applicable) are tnie,Accurate and complete as of the date. ftuaished'to- th> City.

Andrew S, Goodman fteyocabrftTrusidated January 1$. 2002' (Print Pt type narjue of Disclosing Party)

(Sigii here) Andrew Goodman

If l/tui j ■ .      

. My commission

(Print pr type name of person sighing) Trustee

(Print or type title of person signing)

 

Signed and sworn to before mc on (date) ^Ju|y ¹¹       .2014

at Cook County      Coyjjjy, Wipo's^      (state).

Notary Public.

Comm

ission expires:      I J) jJ        ~?.

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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTAIENT HEADS

This Appeiidixis to be conm.lere^      entity whicli hajs a direct

ownership interest in the Applicaitt excecdlifg 7,5 percent It is hot tone com pletedbynny legal entity wliich lias only nu ^

UnderMunicIp^Cbde $e^ or any 'Applicabl^parf/' ;q? ahyJpou,$e/ dr;£)pmejstjc Partner thereof mmently has-a "familial i^iatipr^ljjjp:'HyiM any elected cily official or department head. A, ^familial relationship'* exists if, as of the date uiis EDS; is signed, the DisclrajugPatty or.d\\^App1j'mU^ Party'* or any Spbiis&br Domestic Partner thereof isrefot.ed id : the mayor, any atdennan> the oily clerl?> the city treasurer or any citydepartmertt head as spouse or don^ealig partner or as any of the following_y\yhetherby blood or adopttom: parent, child, brother or sister, aunt ov tincfei' niece or nephew, grandparehti^andchUdi fatlier-mrlaw, mother-in-'lnw,.son-it}-law, daughtef-in#w,:StejjfJltber or stepmother, stepson pr stepdanghter-i'stepbrother or stepsister or half-brother Or balk-sister.

"Applicable Party¹'means ($ all pxeputiyp officers Of the Disdosmg Parry listed in. Section ILBvl#,_r.i£tb;^: Disclosing Party is a coloration) alliEartners;oF.the DisclosiugParty, if the Disclosing; Party is a general partnersliipj ail gehejaipartnersand imUtep'^patiners: of tlie/DiSdqSing .Party, if the Disclosing Party is a limited', partnerships all managers, tjt^^gm^^-imd ipeniberf of fheDistjIbsing Party, if the Oiselosirtgpis^ I$:a' 1 inyted liability company; ,^2) albprincqjal officers ofthe Disclosing Party; and (3) any person having rnpre- than a 7.5 percent ownership int^ttst ipthe Piscjosing 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 orany "Applicable Party" pr any Spouse or Domestic Partner thereof currently have a "familial relationship" with ah elected city official or department head?

[ ] Yes VY] No

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

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Commissioner of DPD (the "Commissioner") or a designee of the Commissioner (each, an "Authorized'Officer") are each hereby authorized, subject to approval by the Corporation Counsel, to enter into and execute such agreements and instruments, and perform any and all acts as shall be necessary or advisable, in connection with the implementation of the Third Restructuring. Each Authorized Officer is hereby authorized, subject to approval by the Corporation Counsel, to enter into and execute such agreements and instruments, and perform any and all acts as shall be necessary or advisable in connection with any future restructuring of the Loan which does not substantially modify the Material Terms.

Section 3. Notwithstanding anything to the contrary contained in the Municipal Code of Chicago (the "Municipal Code") or any other ordinance or mayoral executive order, no parties other than the owners of the Property as of the date following the date of the closing of the Third Restructuring (collectively, the "Owner"), any legal entities which are direct owners in excess of 7.5% ofthe Owner which changed in connection with the Third Restructuring, and all legal entities who constitute the direct or indirect controlling parties of the Owner (as determined by the Corporation Counsel), shall be required to provide to the City the document commonly known as the "Economic Disclosure Statement and Affidavit" (or any successor to such document) in connection with the Third Restructuring.

SECTION 4. To the extent that any ordinance, resolution, rule,-order or provision of the Municipal Code, or part thereof, is in conflict with the provisions of this ordinance, the provisions of this ordinance shall control. If any section, paragraph, clause or provision of this ordinance shall be held invalid, the invalidity of such section, paragraph, clause or provision shall not affect any of the other provisions of this ordinance.

SECTION 5. This ordinance shall be effective as of the date of its passage and approval

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