ORDINANCE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the B1-1 Neighborhood Shopping District and C3-1 Commercial, Manufacturing and Employment District symbols and indications as shown on Map No. 7-L in the area bounded by
West Diversey Avenue ; a line 300 feet east of and parallel to North Lavergne Avenue; the east-west public alley south of and parallel to West Diversey Avenue; a line 50.00 feet east of and parallel to North Lavergne Avenue
to those of a C3-1 Commercial, Manufacturing and Employment District SECTION 2. This ordinance takes effect after its passage and approval.
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Common Address of Property: 4931 -4951 West Diversey Avenue
June 10,2015
Honorable Daniel S. Solis Chairman, Committee on Zoning 121 North LaSaUe Street Room 304
Chicago, Illinois 60602
Dear Committee Members:
The undersigned, William J.P. Banks, being first duly sworn on oath, deposes and says the following:
That the undersigned certifies that he has complied with the requirements of Section 17-13-0107-A of the Chicago Zoning Ordinance by sending the attached letter by United States Postal Service first class mail on such property owners who appear to be the owners of said property within the subject area not solely owned by the applicant, and on the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet, and that the notice contained the address of the property sought to be rezoned; a statement of intended use of said property; the name and address of the applicant; a statement that the applicant intends to file an application for a change in zoning on approximately June 17, 2015; that the applicant has made a bonafide effort to determine the addresses of the parties to be notified under Section 17-13-0107-A of the Chicago Zoning Ordinance; that the applicant certifies that the accompanying list of names and addresses of surrounding property owners within 250 feet, recognizing the above limits, is a complete list containing the names and last known addresses of the owners of the property required to be served and that the applicant has furnished wt addition a list of the persons so
William J.P. Banks Attorney for Applicant
served.
day of June 2015
Subscribed and Sworn to before me
OFFICIAL SEAL LESLEY D MAGNABOSCO
MOTARY PUBLIC - STATE OF ILLINOIS " "'•'MISSION EXPIRES:iO/25/15
70 W. Madison Street Suite 5300 Chicago, IL 60602
SCHAIN |BANKS
SCHAIN BANKS KENNY & SCHWARTZ LTD
Main 312.345.5700 Fax 312.345.5701 www.schainbanks.com
June 10, 2015
Dear Sir/Madam:
In accordance with the Amendment to the Zoning Code enacted by the City Council, Section 17-13-0107-A of the Chicago Zoning Ordinance, please be advised that on or about June 17, 2015, the undersigned, will file an application for a change in zoning for the property located at 4931-4951 West Diversey Avenue from a Bl-1 Neighborhood Shopping District and C3-1 Commercial, Manufacturing and Employment District to a a C3-1 Commercial, Manufacturing and Employment District.
The owner of the property and the applicant of the Zoning Amendment is 4931 West Diversey Avenue, LLC and 4951 West Diversey Avenue, LLC located at 4949 West Diversey Avenue, Chicago, IL 60639
The purpose of the rezoning is to allow the expansion of the owner's meat processing business located at 4951 West Diversey. The expansion will include a parking lot and a building at 4931 West Diversey. The business will then have an address of 4931-4951 West Diversey.
I am the duly authorized attorney for the applicant and owner. My address is 70 West Madison, Suite 5300, Chicago, Illinois 60602. My telephone number is (312) 345-5700.
PLEASE NOTE THAT THE APPLICANT IS NOT SEEKING TO PURCHASE OR REZONE YOUR PROPERTY. THE APPLICANT IS REQUIRED BY LAW TO SEND YOU THIS NOTICE BECAUSE YOU OWN PROPERTY LOCATED WITHIN 250 FEET OF THE SUBJECT PROPERTY.
William J.P. Banks Attorney for Applicant and Owner
CITY OF CHICAGO
APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE
ADDRESS of the property Applicant is seeking to rezone:
4931 -4951 West Diversey Avenue
Ward Number that property is located in: 31
APPLICANT 4931 West Diversey Avenue. LLC and 4951 West Diversey Avenue. LLC
ADDRESS 4949 West Diversey Avenue
CITY Chicago STATE Illinois ZIP CODE 60639
PHONE 773-237-2919 CONTACT PERSON Woiciech Grot
Is the applicant the owner of the property? YES X NO
If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed.
OWNER
ADDRESS
CITY STATE ZIP CODE
PHONE CONTACT PERSON
If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:
ATTORNEY William J.P. Banks of Schain. Banks. Kenny & Schwartz. Ltd.
ADDRESS 70 W. Madison St Suite 5300 CITY Chicago
PHONE 312/345-5700 FAX 312/345-5701
If the applicant is a corporation please provide the names of all shareholders as disclosed on the Economic Disclosure Statements.
Wojciech Grot
On what date did the owner acquire legal title to the subject property?_
Has the present owner previously rezoned this property? If yes, when?
No
Present Zoning District Bl-1 &C3-1 Proposed Zoning District C3-1
Lot size in square feet (or dimensions') 249.81 x 124.11 = 30,999.3 square feet
Current Use of the property Existing business and vacant building and parking lot
Reason for rezoning the property To expand meat processing business. Currently applicant has a
business in the building located at 4951 West Diversey. The expansion will expand to include a
parking lot and a building at 4931 West Diversey. The business will then have an address of 4931 -
4951 West Diversey.
Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)
The applicant proposes to expand meat processing business. Currently applicant has a business in
the building located at 4951 West Diversey. The expansion will expand to include a parking lot and
a building at 4931 West Diversey. The business will then have an address of 4931-4951 West
Diversey.
14. On May 10, 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)
NO X
contained in the documents submitted herewith are true and correct
i "
COUNTY OF COOK STATE OF ILLINOIS
statementi^ipd the statements com?
bed and Sivoi _ day (if
n 10 before me this 1
April . 20_ 1 5 _ . ;
¦*ww"" OFFICIAL SEAL
A
Date of Introduction: File Number:
Ward:
CITY OF CHICAGO
APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE
ADDRESS of the property Applicant is seeking to rezone:
4931-4951 West Diversey Avenue
Ward Number that property is located in: 31
APPLICANT 4931 West Diversey Avenue. LLC and 2951 West Diversey Avenue. LLC
ADDRESS 4949 West Diversey Avenue
CITY Chicago STATE Illinois ZIP CODE 60639
PHONE 773-237-2919 CONTACT PERSON Woiciech Grot
Is the applicant the owner of the property? YES X NO
If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed.
OWNER
ADDRESS
CITY STATE ZIP CODE
•PHONE CONTACT PERSON
If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:
ATTORNEY William J.P. Banks of Schain. Banks. Kenny & Schwartz. Ltd.
ADDRESS 70 W. Madison St Suite 5300 CITY Chicago
PHONE 312/345- 5700 FAX 312/345-5701
If the applicant is a corporation please provide the names of all shareholders as disclosed on the Economic Disclosure Statements.
Wojciech Grot
On what date did the owner acquire legal title to the subject property?_
Has the present owner previously rezoned this property? If yes, when?
No
Present Zoning District B1-1 &C3-1 Proposed Zoning District C3-1
Lot size in square feet (or dimensions) 249.81 x 124.11 - 30,999.3 square feet
Current Use of the property Existing business and vacant building and parking lot
Reason for rezoning the property To expand meat processing business in existing building and
parking.
Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)
The Applicant proposes to expand the existing meat processing business located at 4931-4951 West Diversey Avenue. The rezoning will include the rehab of the existing 1 story building and parking.
14. On May 10, 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)
NO X
COUNTY Ol7 COOK SI ATI.: OF ILLINOIS
_, beingffirst duly sworn on oath, states that all of the above
statements-'and the statements contained in the documents submitted herewith are true and^orrect.
scribed and Sworii to before me this
day of J April . 20 J 5
Signature of Applicant
OFFICIAL SEAL f
ANNA LYNN f
| NOTARY PUBLICS, STATE Of" ILLINOIS |;
MY edMNilSS'QN ISXPIKES i
FEBRUARY 23. 2017 £
For Office Use Onlv
Date of Introduction:
File Number:
Ward:
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 4931 West Diversey Avenue, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
^ the Applicant
OR
[ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 4949 West Diversey Avenue
Chicago, IL 60639
Telephone: (773)237-2919 Fax: Email: magii.alexdeli@gmail.com
Name of contact person: Wojciech Grot
Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Zoning amendment at property located at 4931-4951West Diversey Avenue.
G. Which City agency or department is requesting this EDS? D™
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
Page 1 of 13
SECTION II - DISCLOSURE-. OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING! PARTY
Limited liability company
Limitejd liability partnership
Joint venture 1
Not-lb'r-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
I J Yes | 1 No
I. Indicate the nature of the Disclosing Party^ Person
| | Other (please specify)
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:
N/A
3. For legal entities not organized in the State: of Illindis: Has the organization registered.to do
business in the State of Illinois as a fo'reign entity? ¦ ' ¦ i !
1. ] Yes | ] No yi'N/A I
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 arejlegal entities. If
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s). :
i I If the entity is a general partnership, limited partnership, limited liability company,jlimited 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.
Title
Manager
NOTE: Each legal entity listed below must submit an ED|S on its own behalf.
Maine Wojc.ifich Grot
2. Please provide the following information.concerning each person or entity haying a direct or indirect beneficial interest (including ownership) in excels 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 113
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 "Nohe.j" NOTE: Pursuant to Section 2-154f030 of the Municipal Code of Chicago ("Municipal Code"), the City may requite any such additional information from any applicant which is reasonably intended to achieve full disclosure.
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Name Business Address Percentage Interest in the
Disclosing Party
Wojciech Grot 4949 W. Diversey AveViue, Chicago, IL 60639 100% !
SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Parly had a "business relatipnsh ip," :as defined in Chapter 2-1 561of the Municipal Code, witli any City elected official in the 12 months before the date this EDS is signed?
Yes [/[ No
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If yes, please identify below the name(s) of such City elected official(s) and describe such relationship^)
SECTION IV DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required'to disclose employees who are paid solely through the Disclosing Parly's regular payroll. ;
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"Lobbyist" means any person or entity whoi 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.pcrson or entity anyjpart of whose duties as an employee of another includes undertaking to influence any legislattvci'or administrative action.
If the Disclosing Party is uncertain whether aidisclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist,:etc.) "hourlyrate" or "t.b.d." is
i not an acceptable response.
William J.P. Banks 70 W Madison, #5300, Chicago1, IL 60602 Attorney Estimated $7,500
(Add sheets if necessary)
| J Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
A. COUR T-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-41.5, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout thp contract's term.
Mas any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any; Illinois ;court of competent jurisdiction?
I 1 Yes t/l No [ | No person directly or indirectly owns 10% or mpre of the
Disclosing Party. j
If "Yes," has the person entered into a court-approved agreement for payment of all sjupport owed and is the person in compliance with that agreement?!
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[ J Yes [ ] No |
B. 1 -URTIIER. CER 11FICA I IONS
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1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article l")(which the Applicant should consult for defined terms (e.g., "doing business']) and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, orjeonspiracy to commit bribery, theft,ifraud, 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.
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The Disclosing Party and. if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 11.3.1. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any fc'dejral, state or local unit of government';
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have not, within a live -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; i j
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;
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have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminjated for cause or default; and j
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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. j
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;1 tinited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors anel 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; ojr 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 thb 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; i
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Parly, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party
or any Contractor nor any Agents have, during theifivc 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 contract or engagement in connection with the
Matter: ' i
bribed or attempted to bribe, on been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the C-ity, the State of Illinois, or any agency of the federal government or of any stale or local governrhent in the United States of America; in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged (guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid ;a fixed price or otherwise; or ,
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conductj; or
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violated the provisions of Municipal CodeiSection 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging!in violation of 720 11.CS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons' List, the Unverified List, the Entity List and the Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
' 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-1 56 (Governmental Ethics) of the
M unicipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part 13 (Further
Certifications), the Disclosing Parly.must explain below:
N/A
Page 6 of 13
if the letters "NA." the word "None," or no response appears on the lines above, it will be conclusively piesumed that the Disclosing Party certified to lhe;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 idate of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the I 2-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipicnt;(if none, indicate v/ith "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A ;|99|! ;
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
I. The Disclosing Party certifies that the Disclosing Party (check one)
[ | is Si/\ is not
a "financial institution" as defined in'Section 2-32-455(b) of" the Municipal Code.
.? If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter-2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City." .
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2~32-455(b) of the Municipal Code) is aj predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additionaljpages if necessary):
Page 7 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it wlill be conclusively presumed that the Disclosing Party certified to the above statements. 1
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D CERTIFICATION REGARDING INTEREST IN CITY BUSINESS !
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j j Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
!
In accordance with Section 2-1 '5 6-1 10 of the Municipal Code: Docs any official or employee of the City have a financial interest in his or fieri own name or in the name of any other person or entity in the Matter? t
| | Yes I/] No
NOTE: If you checked "Yes" to Item D.I., proceed to Items D.2 and D.3. If you checked "No" to Item D.I., proceed to Part E. j
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
Does the Matter involve a City Properly Sale? j
[ | Yes f/| No
If you checked "Yes" to Item D.I., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address. Nature of Interest
4. The Disclosing Party further certifies thal 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^) this EDS all information required by paragraph 2. Failure to
'Page 8 of 13 ¦ j
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City,
s^ 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 fojr damage to or injury, or death of their slaves); and the Disclosing Party has found no such records.| ;
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2. The Disclosing Party verifies that, as a result of conducting the search in step I above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:|
!
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NO TE: 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
I. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: ( Add sheets if necessary): j
(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. 1. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress', an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement. j
Page 9 of 13 !
The Disclosing Parly will submit an updated certification at the end of each calendar quarter in wmch there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.I. and A.2. above.
The Disclosing Party certifies that either:l(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 Codje of 1986 but has not engaged and will not engage in "Lobbying Activities". ;
1 i
5. If the Disclosing Party ;is the Applicant, the Disclosing Party must obtain certificationssequal in
form and substance to paragraphs A. I. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon 'request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
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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. j
h the Disclosing Party the Applicant? >
( ] Yes | ] No
If "Yes," answer the three questions below: I
I . Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CER Part 60-2.)
I .1 Yes | i No |
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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 repcjrts due under the applicable filing requirements?
| ] Yes I ) No ! |
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Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause? j
| ] Yes | | No 1
If you checked "No" to question 1. or 2. above, please provide an explanation: i
Page 10 of 13
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SECTION VII- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE j
The Disclosing Parly 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. j
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters,2-1 56 anil 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking Cit>j 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, (3;'l2) 744-9660. The Disclosing Parly must comply fully with the applicable ordinances. I
If the City determines that any information provided in this EDS |is false, incomplete or iijaccurate, 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
" i i
void), at law, or in equity, including terminating the Disclosing Parly's participation in the Miatter and/or
declining to allow the Disclosing Parly 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 iof treble
damages. j ' ¦ !
h 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
! , j
made available to the public on the Internet, in* response to a Freedom ot Inlormation 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 wilh the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information, submitted
in this EDS. !
The information provided in this EDS must be kepi current. In the event ofchang.es , 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 subjecfto 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 2-1 54-020 of the Municipal Code. j
The Disclosing Party represents and warrants:that: j
jpage 1 I of 13 '
F. 1. The Disclosing Parly 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.
j
F 2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated EntitiesIwill 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 thejU. S. General Services Administration. j
F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any j 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 E. 1., F.2. or F.3. above!, an explanatory statement must be attached to this EDS. 1
CERTIFICATION
Under penally of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants jthat 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'.
4931 West Diversey Avenue, LLC i Print or type name of DisclosingJ^arty)
By:
(Sign here)
Wojciech Grot
(Print or type name of person signing)
Manager
(p/n\l or type title of person signing)
'Notary Public.
I Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
i ' I
i : !
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
i ' ! :
' j
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 .(he 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 HDS 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, auru or uncle, niece or nephew, grandparent, grandchild, father-inMaw, mother-in-law, son-in-law, daugh'ter-in-lawj stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (I) all executive officers of the Disclosing I^arty listed in Section II.B-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 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 orany person exercising similar authority. i
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 (/] No | ;
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title ofithc elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
I
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
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 (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner identified asa building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
tyTNo
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Yes
3. If yes to (1) or (2) above, please identify below the name of the person or legal entity
identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTD7ICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: 4951 West Diversey Avenue, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[/[ the Applicant/owner
OR
[] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 4949 West Diversey Avenue
Chicago, IL 60639
Telephone: (773)237-2919 Fax: Email: magii.alexdeli@gmail.com
Name of contact person: Wojciech Grot
Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
Zoning amendment at property located at 4931-4951 West Diversey Avenue.
G. Which City agency or department is requesting this EDS?_DPD
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
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 [ ] No
1. Indicate the nature of the Disclosing Party Person
| | Other (please specify)
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: N/A
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[ ] Yes [ ] No \/\ N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title Wojciech Grot Manager
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
Wojciech Grot 4949 W. Diversey Avenue, Chicago, IL 60639 100%
SECTION III BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes I/ 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)
]J[ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes L^ No [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[ ] Yes [ ] No
FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B. 1. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
Page 6 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing 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
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is [/] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
Page 7 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ] Yes {/[ No
NOTE: If you checked "Yes" to Item D.I., proceed to Items D.2. and D.3. If you checked "No" to Item D.I., proceed to Part E.
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
If you checked "Yes" to Item D.I., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
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F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated IZntitics delinquent in paying any fine, fee, lax 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 Parly will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not. without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.I., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penally of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
4951 West Diversey Avenue, LLC
(Print or type name of Disclosing Party)
(Sign here)
Wojciech Grot
(Print or type name of person signing) Manager
( Print or type title of person signing)
"OFFICIAL SEAL" Joanna M. Ptatek Notary Public. State of minds My Commission Expires Sept. 17,2015
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 II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes L/l No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
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 (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ ]Yes
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Yes
3. If yes to (1) or (2) above, please identify below the name of the person or legal entity
identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.