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This record contains private information, which has been redacted from public viewing.
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Type:
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Ordinance
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Status:
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Passed
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Title:
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Zoning Reclassification Map No. 1-G at 820-850 W Lake St, 200-208 N Green St and 201-209 N Green St - App No. 18605
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Topic:
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ZONING RECLASSIFICATIONS - Map No. 1-G
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FINAL FOR PUBLICATION ORDINANCE BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. That the Chicago Zoning Ordinance be amended by changing all of the Cl-1 Neighborhood Commercial District symbols and indications as shown on Map l-G in the area bounded by: West Lake Street; a line 50.4 feet east of and parallel to North Green Street; the public alley north of and parallel to West Lake Street; North Green Street; a line 100 feet north of and parallel to West Lake Street; a line 125 feet west of and parallel to North Green Street; a line 110.23 feet north of and parallel to West Lake Street; and a line 200 feet west of and parallel to North Green Street; to those of a C3-5 Commercial, Manufacturing and Employment District. SECTION 2. That the Chicago Zoning Ordinance be amended by changing all of the C3-5 Commercial, Manufacturing and Employment District symbols and indications as shown on Map l-G in the area bounded by: West Lake Street; a line 50.4 feet east of and parallel to North Green Street; the public alley north of and parallel to West Lake Street; North Green Street; a line 100 feet north of and parallel to West Lake Street; a line 125 feet west of and parallel to North Green Street; a line 110.23 feet north of and parallel to West Lake Street; and a line 200 feet west of and parallel to North Green Street; to those of a Business Planned Development. SECTION 3. This Ordinance shall be in force and effect from and after its passage and publication. 820-850 West Lake Street, 200-208 North Green Street, 201-209 North Green Street Chicago. IL 60607 BUSINESS PLANNED DEVELOPMENT NO. PLANNED DEVELOPMENT STATEMENTS The area delineated herein as Planned Development Number TBD, ("Planned Development") consists of approximately 25,619 square feet of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Property"). 200 Green Developer LLCis the "Applicant" for this planned development pursuant to authorization from the Property owners. The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 ofthe Chicago Zoning Ordinance (the "Zoning Ordinance"), the Property, at the time of application for amendments, modifications or changes (administrative, legislative or otherwise) to this Planned Development, shall be under single ownership or designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance. All applicable official reviews, approvals or permits arc required to be obtained by the Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or alleys or grants of easements or any adjustment of the right-of-way shall require a separate submittal to the Chicago Department of Transportation ("CDOT") on behalf of the Applicant or its successors, assigns or grantees. Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Plans. Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Department of Planning and Development ("DPD") and CDOT. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of CDOT. All work proposed in the public way must be designed and constructed in accordance with CDOT Standards for Work in the Public Way and.in compliance with.the Municipal Code of the. City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by CDOT. This Plan of Development consists of these 15 Statements; a Bulk Regulations and Data Table and the following exhibits and plans attached hereto prepared by GREC Architects and dated March 17, 2016 (the "Plans"): an Existing Zoning Map; an Existing Land-Use Map; a Planned Development Property and Boundary Line Map; a Site Plan; a Landscape/Green Roof Plan; Building Elevations (North, South, East and West). In any instance where a provision of this Planned Development conflicts with the Chicago Building Code, the Building Code shall control. This Planned Development conforms to the intent and purpose of the Zoning Ordinance, and all requirements thereof, and satisfies the established criteria for approval as a Planned Development. In case of a conflict between the terms of this Planned Development Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control. The following uses are permitted in the area delineated herein as a Business Planned Development: Hotel/Motel, General and Limited Restaurant, Tavern, Outdoor Patio (including beverage and liquor sales and service at rooftop and at grade), Small and Medium Venues, Banquet or Meeting Halls, Food Applicant: 200 Green Developer LLC Address: 820-850 West Lake Street, 200-208 North Green Street, 201 -209 North Green Street Chicago, IL 60607 Introduced: December 9, 2015 Plan Commission: March 17, 2016 FINAL FOR PUBLICATION and Beverage Retail Sales, Liquor Sales, Medical Service, Office, High Technology Office, Personal Service, Participant Sports and Recreation, incidental and accessory uses and accessory parking. On-Premise signs and temporary signs, such as construction and marketing signs, shall be permitted within the Planned Development, subject to the review and approval of DPD. Off-Premise signs are prohibited within the boundary of the Planned Development. For purposes of height measurement, the definitions in the Zoning Ordinance shall apply. The height of any building shall also be subject to height limitations, if any, established by the Federal Aviation Administration. The maximum permitted Floor Area Ratio ("TAR") for the Property shall be in accordance with the attached Bulk Regulations and Data Table. For the purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations and Data Table has been determined using a Net Site Area of 25,753 square feet and an FAR of 5.0. Upon review and determination, "Part II Review", pursuant to Section 17-13-0610 of the Zoning Ordinance, a Part II Review Fee shall be assessed by DPD. The fee, as determined by staff at the time, is final and binding on the Applicant and must be paid to the Department of Revenue prior to the issuance of any Part II approval. The Site and Landscape Plans shall be in substantial conformance with the Landscape Ordinance and any other corresponding regulations and guidelines. Final landscape plan review and approval will be by DPD. Any interim reviews associated with site plan review or Part II reviews, are conditional until final Part II approval. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation, Fleet and Facility Management and Buildings, under Section 13-32-125 of the Municipal Code, or any olher provision of that Code. The terms and conditions of development under this Planned Development ordinance may be modified administratively, pursuant to section 17-13-0611-A of the Zoning Ordinance by the Zoning Administrator upon the application for such a modification by the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. The Applicant acknowledges that it is in the public interest to design, construct and maintain the project in a manner which promotes, enables and maximizes universal access throughout the Property. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility. 14. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. The Applicant shall seek LEED Silver certification (or equivalent alternative certification, such as Energy Star) and provide a green roof equivalent to an actual total of 52,000 square feet for the building. Applicant: 200 Green Developer LLC Address: 820-850 West Lake Street, 200-208 North Green Street, 201 -209. North Green Street Chicago, IL 60607 Introduced: December 9, 2015 Plan Commission: March 17, 2016 15. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development ordinance lapse, the Commissioner of DPD shall initiate a Zoning Map Amendment to rezone the property to the C3-5 Commercial, Manufacturing and Employment District. Applicant: 200 Green Developer LLC Address: , 820-850 West Lake Street, 200-208 North Green Street, 201 -209 North Green Street Chicago, IL 60607 Introduced: December 9, 2015 Plan Commission: March 17, 2016 BUSINESS PLANNED DEVELOPMENT NO. BULK REGULATIONS AND DATA TABLE Gross Site Area (si): 38,226 Area of Public Rights-of-Way (sf): 12,473 Net Site Area (sf): 25,753 Maximum Floor Area Ratio: 5.0 Maximum Floor Area (sf): SubareaA: 119,155 SubareaB: 9,610 Minimum Off-Street Parking Spaces: 42 Minimum Off-Street Loading Spaces: 1 (10'x25') Maximum Hotel Keys: Maximum Building Height: Minimum Setbacks: 190 149"-0'" In conformance with the Plans Applicant: 200 Green Developer LLC Address: 820 850 Wesl Lake Street, 200-208 North Green Street, 201 -209 North Green Street Chicago, IL 60607 I ntrod uced: Decern ber 9, 2015 Plan Commission: March 17, 2016 mi hUK HUliUUA! SUN Q. < o N o CO I- LU UJ ^ r X < UJ O E 5 < | P LLi UJ cc o o o CN ¦ o CM 08 co ^ LT, <° O 0£ CN UJ r CO ¦ £ "2 • CO LU I LU O O T- X o < LU > UJ _ 0 uj lu 5 Q£ o < Z co a o °Q!2 °° t— *s co"5 w o 0 lu a o or O -, a != 1j < 2 o. NW FOP RHRi ^nAT?n!\s -¦cc s -.o;T VtO:,;; "1 ^'l^ *•¦•¦>*>:,.¦ O' .ir- . 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Department of Planning and Development
CITY OF CHICAGO
TO:
MEMORANDUM
Alderman Daniel S. Solis
FROM:
Chairman, City Council Committee on Zoning
David L. Reifman Secretary
Chicago Plan Commission
March 18, 2016
RE: Proposed Business Planned Development for property generally located at 820-850 W. Lake Street, 200-208 N.Green Street.
On March 17, 2014, the Chicago Plan Commission recommended approval ofthe proposed planned development submitted by 200 Green Developer LLC. A copy ofthe proposed planned development is attached. I would very much appreciate your assistance iii having this introduced at the next possible City Council Committee on Zoning hearing.
Also enclosed is a copy of the staff report to the Plan Commission which includes the Department of Planning and Development, bureau of Planning and Zoning recommendation and a copy of the Resolution. If you have any questions in this regard, please do not hesitate to contact me at 744-5777.
cc: Steve Valenziano
PD Master File (Original PD, copy of memo)
12] NORTH LASALLE STREET, ROOM 1000, CHICAGO, ILLINOIS 60602
City of Chicago Plan Commission
March 17, 2016
Proposed Business Planned Development 200-208 North Green Street
N
EXISTING ZONING MAP
5CAIE MS
200-208 N GREEN ST.
¦ SumiERs | iMAjr:.::"- | g;rieic H
ARCHITECTS
SITE & CONTEXT PHOTOS
200-208 N GREEN ST.
¦ MOTHERS | H I GIRIEIC "1
ARCHITECTS
PROPOSED HOTEL SITE
200-208 N GREEN ST.
- | G|R|E|C ARCHITECTS
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2 STORY . COMMERCIAL | . uSsi I BUILDING I ,'g?| I [EXISTING] { I,i | (9M0SF) I
I I
" WEST LAKE STREET
SITE PLAN . LANDSCAPE PLAN & GROUND FLOOR PLAN
200-208 N GREEN ST.
|1010|
|1010|
WEST ELEVATION
200-208 N GREEN ST.
¦ SS»|E=.t---|c.«hc H
ARCHITECTS
PERSPECTIVE RENDERINGS - LOOKING NORTH
200-208 N GREEN ST.
¦ SWTMJ* ( E =¦-"- | GIBIEIC H ARCHITECTS
PERSPECTIVE RENDERINGS - LOOKING SOUTHWEST
200-208 N GREEN ST.
¦ PARTNERS | 0 I GIRIEIC "1
ARCHITECTS
PERSPECTIVE RENDERINGS - STREETVIEW LOOKING SOUTH
200-208 N GREEN ST.
¦ PARTNERS | E -:.T- - | GIRIEIC "1 ARCHITECTS
REPORT FINAL TO THE CHICAGO PLAN COMMISSION FROM
THE DEPARTMENT OF PLANNING AND DEVELOPMENT
MARCH 17, 2016
FOR APPROVAL: BUSINESS PLANNED DEVELOPMENT
APPLICANT: 200 GREEN DEVELOPER LLC
LOCATION: 820-850 W. LAKE STREET, 200-208 N. GREEN STREET,
201-209 N. GREEN STREET
Pursuant to the provisions of the Chicago Zoning Ordinance, Title 17 of the Municipal Code of Chicago, the Department of Planning and Development hereby submit this report and recommendation on a proposed Business Planned Development for your review and recommendation to the Chicago City Council. The application for the amendment to the Chicago Zoning Ordinance was introduced into the City Council on December 9, 2015. Proper legal notice ofthe public hearing on the application was published in the Chicago Sun Times on March 2, 2016. The Applicant was separately notified of this hearing.
This application is submitted as a mandatory planned development pursuant to section 17-8-0512-B (Tall Buildings) which requires planned development review and approval for any building in a C3-5 Zoning District that meets or exceeds 80 feet.
SITE AND AREA DESCRIPTION
EXISTING LAND-USE MAP
The project consists of two rectangular shaped lots containing a total of 25,619 square feet and is bounded on the north by a 3-story commercial building and a public alley, on the east by 3-story office building, on the south by W. Lake Street and on the west by a 2-story masonry building.
PROJECT DESCRIPTION AND BUILDING DESIGN
The applicant proposes to rezone the site from a C1-1 (Neighborhood Commercial District) to a C3-5 (Commercial, Manufacturing and Employment District) prior to establishing a Business Planned Development. The proposal will establish a multi-story hotel with 190 keys, ground floor retail, restaurant, accessory parking and accessory and related uses. The 12-story hotel building is defined by a three (3) story masonry base accentuated with a steel canopy for the hotel entrance and a storefront at the ground floor of the building. The tower portion of the building sets back at the third floor and is defined by an enlarged architectural windows and metal cladding.
Rendering:
ACCESS/CIRCULATION
Access for vehicular traffic is provided via West Lake Street and leads to 42-accessory parking
spaces. The public alley allows access to (2) 10'x 25' loading berths located at the rear of the
building. Access for pedestrians to the hotel occurs through a hotel entry lobby located along
North Green Street; entrance for retail patrons is located on West Lake Street and North Green
Street.
, LOADING
LANDSCAPING and SUSTA1NABILITY
The applicant must comply with the City of Chicago's Landscape Ordinance. In addition the proposed building is required to achieve building certification and provide a 50% green roof as defined by the City of Chicago Sustainable Matrix.
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W^ST LAKE STREET
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AVAILABLE ROOF AREA 15.655 SF
GREEN ROOF AREA 5,200 SF
PERCENTAGE OF GREEN ROOF 33.5°i
PROJECT TO BE LEED SILVER
GREEN ROOF PLAN
BULK/USE/DENSITY
Reference attached Bulk and Data Table Exhibit. RECOMMENDATION
The Department of Planning and Development has reviewed the project materials submitted by the Applicant and have concluded that the proposed development would be appropriate for the site for the following reasons:
The project complies with the Standards and Guidelines for Planned Developments in the Zoning Ordinance (Section 17-8-0900).
17-3-0400 Bulk and Density standards. The proposed Planned Development would not increase the maximum Floor Area Ratio (F.A.R.) stipulated under the C3-5 District but would remain consistent with the surrounding community. This project will have similar uses as the surrounding areas, which include lodging, commercial and retail uses, and accessory parking spaces.
17-8-0908 Green Design: The proposed hotel building shall be required to achieve basic L.E.E.D certification and provide a 50% Green Roof over the net roof area to satisfy the requirements of the City of Chicago's Sustainable Guidelines.
17-8-0905 Pedestrian Orientation: Primary pedestrian entrances are located at the sidewalk level and allow unimpeded pedestrian flow along N. Green Street and West Lake Street. Furthermore the entire street frontage ofthe building along N. Green Street and W. Lake Street is enlivened by a storefront system looking directly onto the street.
17-8-0904 Transportation, Traffic, Circulation and Parking: Motor vehicle parking would be accessed from West Lake Street and an overhead door leading to a ramp allows vehicular traffic into the parking levels. The parking will be screen via a series of architectural windows.
17-8-0901 Use, Bulk, Density and Intensity: The proposed development is compatible with the character ofthe surrounding area in terms of uses, density, and building scale. The proposed Planned Development would be consistent in bulk, density, and Floor Area Ratio (F.A.R.) with the surrounding area. The proposed project will remain with a maximum Floor Area Ratio (F.A.R.) to 5.0. The height ofthe proposed 12-story (150') hotel building will be consistent and is within the context of the surrounding area.
Based on the foregoing, it is the recommendation of the Department of Planning and Development that the revised application for a Planned Development be approved and that the recommendation to the City Council Committee on Zoning, Landmarks and Building Standards is: "As Amended, Passage Recommended."
Department of Planning and Development
|1010|
FINAL
DEPARTMENT of PLANNING and DEVELOPMENT . CITY OF CHICAGO
RESOLUTION BUSINESSS PLANNED DEVELOPMENT 820-850 W. LAKE STREET, 200-208 N. GREEN STREET, 201-209 N. GREEN STREET
WHEREAS, the applicant, 200 GREEN DEVELOPER; LLC, proposes to establish a Planned Development. The applicant proposes to rezone the site from a C1-1 (Neighborhood Commercial District) to a C3-5 (Commercial, Manufacturing and Employment District) prior to establishing a Business Planned Development. The proposal wiii establish a 12-story hotel with ground floor retail, restaurant, and accessory parking and accessory and related uses; and
WHEREAS, This development is being submitted by the applicant as a mandatory planned development application and an application for a Planned Development was introduced to the City Council on December 9, 2015; and
WHEREAS, proper legal notice of the hearing before the Chicago Plan Commission was published in the Chicago Sun-Times on March 2, 2016. The proposed Zoning Application was considered at a public hearing by this Plan Commission on March 17, 2016. The Applicant was separately notified of this hearing; and
WHEREAS, the Plan Commission has reviewed the applications with respect to the provisions of the Chicago Zoning Ordinance and finds that the proposal will be consistent with said provisions; and
WHEREAS, the Department of Planning and Development recommended approval of the application, with the recommendation and explanation contained in the written report dated March 17, 2016, a copy of which is attached hereto and made a part hereof; and
WHEREAS, the Chicago Plan Commission has fully reviewed the application and all informational submissions associated with the proposed amendment, the report and recommendation of the Commissioner of the Department of Planning and Development, and all other testimony presented at the public hearing held on March 17, 2016 giving due and proper consideration to the Chicago Zoning Ordinance; and
121 NORTH LASALLE STREET. ROOM 1000, CHICAGO ILLINOIS 60602
FINAL
NOW, THEREFORE, BE IT RESOLVED BY THE CHICAGO PLAN COMMISSION:
THAT the final application dated March 17, 2016 be approved as being in conformance with the provisions, terms and conditions of the corresponding Zoning application; and
THAT this Plan Commission recommends approval to the City Council Committee on Zoning, Landmarks and Building Standards of the final zoning application dated March 17, 2016; and
THAT the above-stated recitals to this resolution together with the report of the Commissioner of the Department of Planning and Development be adopted as the findings of fact of the Chicago Plan Commission regarding the zoning map amendment for a Business Planned Development application.
Martin Cabrera, Jr. / / Chairman Chicago Plan Commission
Approved:
March 17, 2016 BPD No.
RECEIVED MAR 1 7 2015
Initial: ^2La-Zi^V
AMENDED
CITY OF CHICAGO
APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE
ADDRESS of the property Applicant is seeking to rezone:
820-850 West Lake Street. 200-208 North Green Street, 201-209 North Green Street Chicago. IL
60607
Ward.Number that property is located in: 27th Ward
APPLICANT 200 Green Developer LLC
ADDRESS 917 W. Washington Blvd. #308 __
CITY Chicago STATE IL ZIP CODE 60607
PHONE 312-690-4050 EMAIL jshapack@shapack.com CONTACT PERSON Jeff Shapack
Is the applicant the owner ofthe property? YES NO X
If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the applicant to proceed.
OWNER Please see attached Exhibit A
ADDRESS
CITY STATE ZIP CODE
PHONE EMAIL CONTACT PERSON
If the Applicant/Owner ofthe property has obtained a lawyer as their representative for the rezoning, please provide the following information:
ATTORNEY Rich Klawiter & Katie Jahnke Dale - DLA Piper LLP (US')
ADDRESS 203 N. LaSalle Street. Suite 1900
CITY Chicago STATE [L
PHONE (312) 368-7243/-2153
ZIP CODE 60601 FAX (312)251-2856
EMAIL Richard.klawiter@dlapiper.com / katie.dale@dlapiper.com
If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements:
See attached Economic Disclosure Statements
On what date did the owner acquire legal title to the subject property? Various dates between 1982
and 2013
Has the present owner previously rezoned this property? If yes, when? No
Present Zoning District Cl-1 Neighborhood Commercial District
Proposed Zoning District C3-5 Commercial, Manufacturing and Employment District then Business
Planned Development
Lot size in square feet (or dimensions) +/- 25.753 square feet
Current Use of the Property Commercial
Reason for rezoning the property Mandatory Planned Development pursuant to Section 17-8-0512
(Tall Buildings)
Describe the proposed use ofthe 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 requests a rezoning ofthe subject property from the Cl-1 Neighborhood Commercial District to the C3-5 Commercial. Manufacturing and Employment District then to a Business Planned Development to permit the construction of an approximately 11-story plus penthouse hotel with ground floor commercial and retail uses, accessory parking and accessory and incidental uses.
The Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units and/or a financial contribution for residential housing projects with ten or more units that receive a zoning change which, among other triggers, increases the allowable floor area, or, for existing Planned Developments, increases the number of units (see attached fact sheet or visit www.cityofchicago.org/ARO for more information). Is this project subject to the ARO?
NO X
(DO NOT SUBMIT THIS PAGE WITH YOUR HDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIF1CATION
Generally, for use with City Council matters. Not for City procurements unless requested.
Planned development approval for 820-850 W. Lake St., This recertification is being submitted in connection with 200-208 N. Green St., and 201-209 n. Green St. [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS recertification on behalf ofthe Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date furnished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.
Shapack Investments LLC Date" ^^ ""
(Print or type legal name of Disclosing Party)
By
Print or type name of signatory: Jeffrey Shapack
Title of signatory: Manager
U2
Signed and sworn to before me on [date] 3 ""3- ~~
(JfffrfXj Pfrflfft/1^, at _jCMK- County
14
Notary. Public.
Commission expires:
[state].
LINDSEY RIDGWAY OFFICIAL SCAL Notary Public. State ol iliincis My Commission Expiiet August 20. 2019
Ver. 11-01-05
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Check ONE ofthe 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: ^Qf) &f£JWl. UPAofiPr LUC >
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:
Business address of the Disclosing Party:
Telephone: ftl^- Lo^Q- 4fi/tQ Pax: Email: t j ^a^cX0JC/7> ^\\S^^-c()(Y
Name of contact person: Ckffff/j ^^JtjItXLilC
Federal Employer Identification No. (if you have one): j '*" ^
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):
plMAM fo.u/bfrtesvt AjffflaJ for 4,00- 0.01 m.fofc^gV.
Which City agency or department is requesting this EDS? J/fcft-. jj) f^a^KYl A- tt^eXn^fflCO V
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract # .
Page I of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of the Disclosing Party:
Person hcj 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 of Illinois: Has the organization registered toido business in the State of Illinois as a foreign entity?
[I Yes NNo [ ] 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% 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 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 ofthe 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)
Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V-CERTIFICATIONS i
COURT ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or-more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [$ No [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party:
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[JYes . []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.l. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
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 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:
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, orany 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 ofthe 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 ofthe Treasury or the . Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the. Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Page 6 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
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").
—
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 ofthe City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one) -
[ ] is |Y1 is not
a "financial institution" as defined in Section 2-32-455(b) ofthe 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 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 of any other person or entity in the Matter?
[ ]Yes .; . ' fv|N.o : ¦
NOTE: If you checked "Yes" to Item D. 1., proceed to'ltems D.2. and D.3. If you checked "No" to Item D. 1., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or dtherwise'permitte'd; no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs.to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the.City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[]Yes []No
If you checked "Yes" to Item D. 1., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13-
I
I
comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
_X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of
the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure, Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
. 2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.I. 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 6r 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.
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.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party arid its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any ' ': contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and Fl2. above and will riot, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that-the-Disclosing Party, has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS'. ¦¦ ' '
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) oh'behalf ofthe Disclosing Party, arid (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true. accurate and complete asi of the date 'furnished to the City. '
(Print or type name of Disclosing Party)
(/Sign here)
(Print o'r type harriVof person'signiri'g)
(Print or type title of person signing)
Signed and sworn to before me on (date) I <^
at COO £- County, 27////fgl' f (state).
LINDSEY R IDG WAY OFFICIAL SEAL Noiary Public, Siaie ol Illinois My Commission Expires August 20. 2019
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this 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 [jfj No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
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 bWnershipinterest ih
the Applicant. " -
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord1 pursuant to Section 2-92*416 of the'MunicipaT
' Code?" ' " ' ¦'¦ '' ' ""': ¦ • •"¦
[ ]Yes f^No
If the Applicant is a legal entity publicly traded oh 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 ofthe Municipal Code?
T ] Yes ; []Nc [X] Not Applicable
If yes to (1) or (2) above, please identify below the name ofthe person or legal; entity -identified as a building code scofflaw or problem landlord and the address of thebuilding 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.
(DO NOT SUBMIT THIS PAGE WI TH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
Planned development approval for 820-850 W. Lake St., This recertification is being submitted in connection with 200-208 N. Green St., and 201-209 N. Green St. [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS recertification on behalf ofthe Disclosing Parry, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date furnished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.
200 Green Developer LLC
(Print or type legal name of Disclosing Party) By:
(sign here)
Print or type name of signatory: Jeffrey Shapack
Title of signatory: Manager
Signed and sworn to betore me on [date] jj^
J'rfrfj VJi^mic , at ___Cj2rK
Tommission expires:
Ver. 11-01-OS
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:
| Check ONE of the following three boxes:
j Indicate whether the Disclosing Party submitting this EDS is:
60 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:
Business address of the Disclosing Party: %*S> % [jjj. Af IYU \tU^L ArV~l fcUOD
Telephone: 3&-fo?fl "frOUO Fax: . . Email: JS\VtfCUlkJ^ $fof&£t(6vr
Name of contact person: ^Jfj-J-fSAj $Yl CtQAJL^
Federal Employer Identification No., (if you have one): ^ . . ._.
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
G. Which City agency or department is requesting this EDS? ^yf. 0^ //&ftyuVlj fad Ih/fi^tilt
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract U
Page 1 of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
Person f$ 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 of Illinois: Has the organization registered to-do j business in the State of Illinois as a foreign entity?
| IX] Yes rjNo [ ] 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, j 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.
i
j. Name Title
j J^fjYCLj^ShA^M^. gAj^a^Ajz
I _ : : _ .
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
Disclosing Party
cliVcAy, T-L i^pbiA-
j' j
| 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 5 ){no
i
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
i
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
I Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
j retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
j to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
| Attorney - Retained not an acceptable response.
' Vlk Zo?. >¦* • L*-SE^QQ l-Wc^zl i/OUl g^-h &XV>Q0O
Architect - Retained
(Add sheets if necessary)
\, [ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
j'
! SECTION V -- CERTIFICATIONS
i
i
! 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 obligation's by any Illinois court of competent jurisdiction?
[ ] Yes D^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 o'f all support 6wed: and is the person in compliance with that agreement?
[]Yes []No
B. FURTHER CERTIFICATIONS
I . Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal 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.l. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
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 ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to 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 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 of 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; of
violated'the provisions of Municipal Code Section 2-92-610 (Living WagesOrdinance)
Neither the Disclosing Party, Affiliated Entity ;of 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 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.
The Disclosing Party understands and shall comply with the applicable requirements; of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Page 6 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-; month period preceding the execution date of this EDS, an employee, or elected or appointed official, • ofthe City of Chicago (if none, indicate with "N/A" or "none").
M
t ¦»
j 9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
j 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 j 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 j with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
j vjA
j C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
i
I [ ] is fiQ is not
j •
| a "financial institution", as defined in Section 2-32-455(b) ofthe Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
j "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 i 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 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 of any other person or
entity in the Matter? : : '
["] Yes . s p{No '
NOTE; If you checked "Yes" to Item D.l., proceed to Items Di2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or btherwise'permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes []No
If you checked "Yes" to Item D.l., provide the names and: business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
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 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee 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 Appiicant, 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 xequire, 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?
[JYes [JNo
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[JYes [JNo
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 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.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing'Party and its Affiliated Entities will not use, nor permit their subcontractors to use, ahy facility listed by the U.S. E.P.A, on the federal Excluded Parties List System ("EPLS") maintained by the Ul 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^E and F.2.: abdve 'and will not, without the prior written consent of the City, use any such contractor/subcontractor that'dbes riot provide such certifications or. that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS. : -
CERTIFICATION
Under penalty of perjury, the person signing below: (1) waffahts that he/she is authorizedrto 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)
^ ff^j Sa^p
(Print or type name of person signing)
(Print or type title of person signing)
Signed and sworn to before me on ^date) I St.-1- IS
at jOO^ County, T^IlMHS (state).
Notary Public. 1 ,*i>gF%, lindsey ridgway
OFFICIAL SEAL NoiaiY Public. Stale of Mlincjn My Commission Expues
Commission expires
August 20. 2019
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this 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
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
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 toMunicipal Code'Sectiori 2-154-010, is the Applicant or any Owner identified as a
building code'scofflaw or problem landlord pursuant to Section 2-92:;4l6:of the Municipal
Code? ' '
f JYes ty] No
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?
| JYes [JNo • [XJ Not Applicable
If yes to (1) or (2) abovej please identify.below the name of the person or legal entity identified as a building code scofflaw of 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.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
Planned development approval for 820-850 W. Lake St., This reccrtification is being submitted in connection with 200-208 N. Green St., and 201-209 N. Green St. [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as ofthe date furnished to the City and continue to be true, accurate and complete as ofthe date of this recertification, and (3) reaffirms its acknowledgments.
820 Partners LLC Date: 3 " ^- *"
(Print or type legal name of Disclosing Party)
Print or type name of signatory: Jeffrey Shapack
Title of signatory: Manager
Signed and swom to before me on [date] 7,-9- 'I U?
Jeffr/A ,?htU7MkL, at _Jm}C County,.
'ommission expires: • o^O j I °
Ver. 11-01-05
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
LLC-
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
2. [] a legal entity holding a direct or indirect interest in the Slate the legal name of the
Applicani in which the Disclosing Parly holds an interest:
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name ofthe entity in
which the Disclosing Party holds a right of control:
Business address ofthe Disclosing Party: f? f\c_i,J^k^2^__x_L U0Jd±. _
Telephone: '*>)2-b<\0rName of contact person: Jje^jfr&Lj SW<^Federal Employer Identification No. (if you have one): 20 " O^S 4* Cfl 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):
Which City agency or department is requesting this EDS? ty_r?i~. (h^ ^f&flniAcj If the Mutter is a contract being handled by the City's Depariment of Procurement Services, please complete the following:
Specification// and Contract # _ _
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
] 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 of Illinois: Has the organization registered to do business in the State of Illinois as.a foreign entity?
$Yes []No []N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name r Title
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None.'" NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
577 £ZQ Member LU; li). fam\hl$L Avi _7
La&_ &ffse#i LLP fZO U). UU sb. & O V ¦
MCAjff, Tl* Lcfl(».Q>
SECTION III -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[]Yes p^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 ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who arc paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity 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.
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)
[t^/Check here if the Disclosing Party has not retained, nor expects to.retain, any such persons or entities. SECTION V --.CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the'Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes No [ ] ¦N^Tperson directly or indirectly owns 10% or more of the
Disclosing Parly.
If "YeSi" 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 Parly and, if the Disclosing Parly 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 volunlarily excluded from any transactions by any federal, stale 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 properly:
arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
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 Parly;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Parly 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 Entiiy 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 Parly, any Contractor or any Affiliated Entity or any olher official, agent or employee of ihe 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 Entiiy (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 lo bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the Slate of-Ulinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with olher bidders or prospective bidders, or been a parly 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 agrccment 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).
A. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33 E--1: or (3) any similar offense of any state'or ofthe United States of America (hat conrains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity:is listed oh anyof the following lists maintained by the Office of Foreign Assets Control, of the U.S. Depariment of ihe Treasury or the Bureau of Industry and Security ofthe U.S. Depariment of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, ihe Unverified List, ihe Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements oi" Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of ihe Municipal Code.
If the Disclosing Party is.unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Parry must explain below:
Page 6 of 13
If the letters "NA." the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best 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, of the City of Chicago (if none^ridieale with "N/A" or "none").
9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts (hat 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, ofthe City of Chicago. For purposes of this statement, a "gift" docs not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, plensc also list the name ofthe City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION I. The Disclosing Party certifies that the Disclosing Party (check one)
a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.
2. 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. Wc 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 ofthe privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32--155(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 ihe 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 2-1 56 ofthe Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-1 10 ofthe Municipal Code: Does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
I ] Yes J$No
NOTE: If you checked "Yes" lo Item D.l., proceed to Hems D.2. and D.3. If you checked "No" to Item D.l' proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for raxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power docs not constitute a financial interest within the meaning of this Pari D.
Docs the Matter involve a City Properly Sale?
[ ] Yes [ ] No
If you checked "Yes" lo hem 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 Parly further certifies that no prohibited financial interest in the Mailer 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 Parly must disclose below or in an attachment to this EDS nil information required by paragraph 2. Failure lo
Pane 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 in jury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step I above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Parly 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 MA TTERS ,
NOTE: If (he Matter is federally funded, complete this Section VI. If the Matter is noi federally funded, proceed lo Section VII. For purposes of this Section VI. tax credits allocated by the City and proceeds of debt obligations ofthe City arc not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing 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 ihe Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.I. above for his or her lobbying activities or lo pay any person or entity to influence or attempt lo influence an officer or employee of any agency, as defined by applicable federal law, a member ol" 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 ofthe statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Parly certifies that cither: (i) it is not an organization described in section 501 [c)(4) of the Internal Revenue Code of 1986: or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has noi engaged and'will not engage in "Lobbying Activities".
If the Disclosing Parly 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 ihe Matter and must make such certifications promptly available to the City upoivrequesi.
13. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal¦ regulations,requirc,thc Applieant-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
tf "Yes," answer ihe three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (Sec A 1 CFR Part 60-2.)
' | J Yes | JNo
Have you filed with the Joint Reporting Committee, the Director of Ihe Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ J Yes [JNo
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ J No
1 f you checked '"No" ro question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Parly 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 olher 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 vvww.cityofchicago.org/Eihics , 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 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 of treble-damages.
lt is the City's policy lo.mnke this document available to the public on its Internet silo and/or upon request. Some or all ofthe information provided on this EDS and any altachments'to this F.DS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS. the Disclosing 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 lo the time (he City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Partv 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 ihe Municipal Code.
The Disclosing Party represents and warrants that:
Page I 1 of 13
F.l. The Disclosing Part)' is not delinquent in the payment of any lax administered by the Illinois Deportment of Revenue, nor arc the Disclosing Party or its Affiliated Entities delinquent in pitying any fine, fee, lux 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 Parly is the Applicant, the Disclosing; Ptirly will obtain from any contractors'subcunrractors hired or lo be hired in connection with the Matter certifications equal in form and* substance to those in F. 1. and F.2. above and wiif not.Avithout the prior written consent ofthe City, use any such contractor/subcontractor that does not provide.such certifications or that the Disclosing Parly has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l cxplanalory'slatemenf 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 thcDisclosing Parly,- 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)
i»n here)
(Print or type name of person signing) Manager
(Print or type title of person signing)
Signed and sworn to before mc on (date)
at County. ~&L- _____ (stale).
^ Notary Public.
Commission cxpircs:i2^^i^_^_.ZSt?.-
Paye 12 of 13
UNDSEY RiDGWAY OFFICIAL SEAL Noiary Public. Sia:? ol Mm-' My CoitiiiiisSio.i L*rjii<
Augosi 20. 2019
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AM) 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.
Linder 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 relationship1' with any elected city official or department head. A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any 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 II.B.La., 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 ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Parly; 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 jj^No
If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX II
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 715 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
: I. Pursuant to Municipal Code Section 2-15-4-010. is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Seel ion 2-92-416 ofthe Municipal Code?
I JYes fj^No
If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant'idcnlificd as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?
[ | Yes | JNo -j^jNot Applicable
If yeSilo (1) or (2) above, please identify below the name ofthe person or legal entity identified as a building code scoffiaw 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 ANI) AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIA TED EDS, ANI) THAI' THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT 'TO THE CERTIFICA TION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OFTHE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION Generally, for use with City Council matters. Not for City procurements unless requested.
Zoning map amendment for property located at This reccrtification is being submitted in connection with 444-e50W st and 832-g34 w Lak0 st- Chicago. Illinois [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date furnished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.
Chicago Titta Land Trust Company . tJ ¦*> 0lL>
Trust Number 10-40268-09 dated August 9.1982 Date: M-AE*-** i
(Print or type legal name of Disclosing Patty)
.. r - (sign ten
(sign here)
Print or type name of signatory:
Ronald Vala Angela BurWsy
Title of signatory:
50% Holder of Benaficial Interest and Power of Direction 50% Holder of Benaficial Interest and Power of Direction
by Ronaid Vaia ^ y q / L
Signed and sworn to before me on [date] 'A If by
Commission expires:
Ver. 11-01-05
Notary Public Commission Expires:
\ / V at co
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if anolicable: Chicago Title Land Trust Company, Trust Number 10-40268, dated August 9, 1982
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[y_ the AgeJjggjTiJ owner of 844-850 W. Lake Street and 832-834 W. Lake Street also known
OR - 200-208 N. Green Street
[ ] 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. f ] a legal entity with a right of control (see Section II.B.l.) Stale the legal name of the entity in
which the Disclosing Party holds a right of control:
Ronald Vaia and Angela Burkley C/O
B. Business address of the Disclosing Party: Attorney Michael J. Polachek
1000 Hart Road, Suite 300
Barrin^ton, I-L 60010
r- t i u 224-655-2991 r- 224-655-2993 mDolachek(?polacheklawfirm.com
I elepnone: Fax: Email: ¦
Name of contact person: Attorney Michael J. Polachek
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 man amendment for property located at 444-850 W. Lake Street and 832-834 W. Lake
-S^gegt, Chicago,—IL —:
Which City agency or department is requesting this EDS? Department of Planning & Development
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
1. Indicate the nature ofthe Disclosing Parry:
f ] 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
Jq} 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 of Illinois: Has the organization registered to do business in the State, of Illinois as a foreign entity?'
[]Yes -tlNo XfKfN/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 Chicago Title Land Trust Company Trustee
as^TrusEee UTA 10-40268-09 dated August 9, 1982
Ronald Vaia Holder of Power of Direction
Angela Burkley Holder of Power of Direction
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
Ronald Vala 146 Hillcrest Court :
Barrington, IL 60010 .~: ¦'
Angela Burkley ' 42383 N. Oak Lane _J J
Antioch, IL 60003
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 HNo
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)
Pf" 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 Temain 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?
[ j Yes |X] No [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support 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 lias 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.l. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
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 p.erson or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, undeT 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, ot, with the Contractor, is under common control of another person or entity;
any responsible official ofthe 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 fhe date this EDS is signed, or, with respect to a Contractor, an Affiliated Entiiy. or an Affiliated Entity of a Contractor during the five years before thc-date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
a-, bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; :or 1
madejan admission of such conduct described iii 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.
6. . The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe
Municipal Code.
7. If the. Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
Page 6 of 13
If the letters "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").
NONE
9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name, of the City recipient.
NONE
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is [X] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 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 ot 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) 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
rf the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-156 of the 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
ofthe 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 U No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.l and D.3. If you checked "No" to Item D.l., proceed to Part E. !'
Unless sold pursuant to a process of competitive bidding, or otherwise.permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any .other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes .or assessments, or (iii) is sold by-virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power docs not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes [ ] No
.3. If you checked "Yes" to Item D.l., provide'the names and business addresses of the City officials or employees having such interest and 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.
XX 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 ofthe 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) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe 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 theApplicant and all proposed . i' "
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.)
[JYes [JNo
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 • n No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
? Yes [JNo
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 contractor 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.citvofchicago.org/Ethics . and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
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 ot voidable, and the City may pursue, any remedies undcT 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 ofthe 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! 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 H of 13
F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the DisclosingParty 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.I. arid F.2. above and will not, without the prior written consent of the City, us& any such coritTactor/subcontfactor that does not provide such certifications or that the Disclosing Party has reason-to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F. 1., F.2. or F.3. above, an explanatory statement must'be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized tor execute this EDS and-Appendix A (if applicable) on behalf of the Disclosing Party, arid (2); warrants that all certifications and statements contained in this EDS aiid Appendix A (if applicable) are true, accurate and completers of the date furnished to the Cirv. Chicago Title Land Trust Company, Trust Number
10-40268, dated August 9, 1982 (Fruit owtype name of Disclosing Party)
By: /j£r?
(Sign here)
Ronald Vaia
Angela Burkley
Y
by Ronald Vaia
Signed and swom to before me\on (date)
at £ County, ¦•.Sit-'--'
Commission expires:
Official Seal Michael J Polachek Notary Public State of Illinois My Commission Expires 06/10/2019
50% Holder of Beneficial Interest and Power of Direction
_(state). Notary Public.
Signed and sworn to before rae by Angela
I,. f .-Burkley on U - M * & at folfy County
-' State of Illinois.
Notary PubliLy
Conmiission Expires: tf '/tb " ^i*1/ 6?
Page 12 of 13
BARBARA J.STUBBS NOTARY PUBUC, STATE OF ILLINOIS MY COMMISSION EXPIRES 9/13/2016
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 ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any 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, sonrin-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 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 ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes £x] No
If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
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 jegal 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.
Pursuant to'Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building codescofflaw or problem landlordpursuant to Section 2-92:416 ofthe Municipal Code? ;.
[,. ] Yes IxJNo
If the Applicant is a legale entitypublicly traded on any exchange, is any officer or director of the Applicant identified as a buildingicode scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?
[JYes - [ ] No P] Not Applicable
If.yes to (l)-or(2) above, please identify, below thename ofthe person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which me pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDED 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.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information) j
RECERTIFICATION
t City Council matters. Not for City procurements unless requested.
This recertification is [identify the Matter].
Planned development approval for 820-850 W. Lake St., Deing submitted in connection with 200-208 N. Green St., and 201-209 N. Green St. Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as ofthe date furnished to the City and continue to be true, accurate and complete' as of the date of this recertification, and (3) reaffirms its acknowledgments.
Lake Green LLC
(Print or tyjflb legal name of Disclosing Party)
Title of signatory Manager
[state].
Signed and sworn to before me on [date] ff\_i^T.Y\ ^ J If ,by KOtPrt Ka + Z. 1 at faff£ County, X L.
Notary Public.
Commission expires: fyjJJ^ ¦ $0 j (001 °i
LINDSEY RIDGWAY OFFICIAL SEAL Notary Public, Slate of Illinois MyCommission Expires Augusi 20. 2019
Ver. 11-01-05
j
A
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
/ AND AFFIDAVIT
/oN I - GENERAL INFORMATION
/
yT_ega! name ol the Disclosing Part)' submitting this EDS. Include d'b/a/ if applicable:
/ LfiKt LLC
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
2. a legal entity holding a direct or indirect interest in the 'YpnttHA -TMate the legal name of the
Applicant in which the Disclosing Party holds an interest: %lJ0 pdf~lYlC*'S LLC*
OR
3. [] a legal entity with a right of control (see Section 11.B. 1.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
Business address ofthe Disclosing Party: %'ZJ) \)J • LaJCjL^ SV ¦
Telephone: "773 ' 23^^333^: Email: frOl^j^. COirY*
Name of contact person:
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): \jO\-'l,t>c
G. Which City agency or department is requesting this
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification if and Contract ii
Page 1 of 13
SECTION H - DISCLOSURE OF OWNERS!!!!' INTERESTS
A. NATURE OFTHE DISCLOSING PARTY
1. Indicate the nature ofthe Disclosing Party:
[] Person Limited liability company
[ ] Publicly registered business corporation [ ] Limited liability partnership
[ ] Privately held business corporation [ ] Joint venture
f J Sole proprietorship [ ] Not-for-profit corporation
[ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))?
[] Limited partnership I J Yes [ ] No
f ] Trust [ J Olher (please specify)
2. For legal entities, the stale (or foreign country) of incorporation or organization, if applicable:
3. For legal entities not organized in ihe Suite of Illinois: Has ihe organization registered to do business in the State of Illinois as a!foreign entity?
^Ycs [JNo [J N/A
B. 11- THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any. which arc legal entities. If there arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal litleholdcr(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below Ihe name and title of each general partner, managing member, manager or any other person or entity that controls Ihe day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title . . ,
Vob^ MUA^ ; __________ Member/Manager
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 Parly. Examples of such an interest include shares in a corporation, partnership intercsi 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, stale "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 w hich is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosinsi Partv
2o)Q&Yr M~L STjQ UJ> ItMiSh|99| sol.
]6^vvj£eJam 32SLuLduk*-$hL
SECTION HI -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the 12 months before the dale this EDS is signed?
[]Ycs I^No
If yes, please identify below the name(s) of such City elected official(s) and describe such relationship^):
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND O THER 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 ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who arc 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 entiiy 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 cither ask the City whether disclosure is required or make the disclosure.
Name (indicate whether Business Relationship lo Disclosing Party Tees (indicate whether
retained or anticipated Address (subcontractor, attorney. paid or estimated.) NO TE:
lo be retained) lobbyist, etc.) '"hourly rate" or "t.b.d." is
noi an acceptable response.
(Add sheets if necessary)
[v^Check here if the Disclosing Party has not retained, nor expects to. retain, any such persons or entities SEC TION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-4 15, 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 Parly been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] 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?
[ ] Yes [ j No
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23. Article I ("Article l")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of. or has ever been convicted of. or placed under supervision for. any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the Applicant understands and acknowledges thai 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.
Pa tie 4 of 13
Tlic Disclosing Party and. if the Disclosing Party is a legal entiiy, all of those persons or entities identified in Section II.B.l. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, stale 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 slate 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, slate or local) with committing any ofthe offenses set forth in clause 13.2.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, slate 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 ihe 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 Parly 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 Parly, or is, with the Disclosing Party, under common control of another person or entiiy. Indicia ofcontrol 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 stale or local government, including the City, using substantially the same management, ownership, or principals as ihe ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity (hat directly or indirectly controls the Contractor, is controlled by it, or. with the Contractor, is under common control of another person or entity;
¦ any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Parly, any Contractor or any Affiliated Entiiy. acting pursuant lo 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 Entiiy 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 (he United Stales of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a parly 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
. c. 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
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance),
Neither the Disclosing Party, Affiliated Entiiy 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 (I) bid-rigging in violation of 720 ILCS 5/33E-3: (2) bid-rotai.ing in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any stale or of the United Stales of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entiiy is listed on any ofthe following lists • maintained by the Office of Foreign Assets Conlrolof the U.S. Department ofthe Treasury or the Bureau of Industry and Security ofthe 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) ofthe Municipal Code.
If the Disclosing Party is unable to certify lo any ofthe above statements in this Part 13 (Further Certifications), the Disclosing Party must explain below:
Page 6 of 13
If the loiters "NA." (ho word "None," or no response appears on (he lines above, it will be conclusively presumed that the Disclosing Party certified lo the above statements.
8. To the best ofthe Disclosing Parly'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").
. ' ... ...
9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts thai the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution dale of this EDS, to an employee, or elected or appointed official, ofthe City of Chicago. I-or purposes of this statement, a "gift" does not include: (',) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "'N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
zzzzzr -z=zzzz_.___—-
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Parly certifies that the Disclosing Party (check one)
[ ] is ^ is not
a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Parly pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge thai none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."
If the Disclosing Party is unable lo make this pledge because il 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 tlic 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 CJTY 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.
ln accordance with Section 2-1 56-110 ofthe Municipal Code: Does any official or employee ofthe City have a financial interest in his or her own name or in the name of any.other person or entity in the Matter?
M Yes L$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.l proceed to'Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted; no City elected official or employee shall have a,financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively. "City Property Sale"). Compensation for properly taken pursuant to the City's eminent domain power docs not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Properly Sale?
[ ] Yes j | No
If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing Parly 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 cheek either 1. or 2. below. If the Disclosing Party checks 2 the Disclosing P;wiy must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page S' of 13
comply with these disclosure rcquiremcnis may make any contract entered into with the City in connection with the Matter voidable by the City.
1. The Disclosing Parly verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Parly verifies that, as a result of conducting the search in step 1 above, the
Disclosing Parly has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Parly 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
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):
(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 (he Disclosing Parly means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds lo pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entiiy to influence or attempt lo 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 w'nh 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
Tlic 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.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section
50J (c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Parly is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs AM . 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 ofthe Matter and must make such certifications promptly available to the City upon request.
13. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNIT Y
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit (he following'information with their bids or in writing at the outset of negotiations.
Is the Disclosing Parly 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 4 I CFR Part 60-2.)
| ] Yes f ] No
Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports clue under the applicable filing requirements?
[JYes " [JNo
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
I JYes • UNo
If you checked "No" to question I. or 2. above, please provide an explanation:
Pa»e 10 of 13
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION. COM PLIANCE, PENALLIES, DISCLOSURE
Tlic 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 arc material inducements to the City's execution of any contract or taking other action with respect lo the Matter. The Disclosing Party understands (hat it must comply with all statutes, ordinances, and regulations on which this EDS is based.
13. 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 w ww.cilyofchicatio.oru/'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), ai 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,\vilh 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 ofthe 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 Parly waives and releases any possible rights or claims which ii 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 (he time the City takes action on the Matter. If (he Matter is a
contract being handled by the City's Department of Procurement Services, (he Disclosing Parly must
update this EDS as the contract requires. NOTE: With respect lo 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 lunger period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Parly represents and warrants that:
Pane 11 of 13
F.l. The Disclosing Part}' is not delinquent in the payment of any tax administered by the Illinois Depariment of Revenue, nor are (he Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to (he 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 (he Disclosing Parly is (he 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 tlic Matter certifications equal in form and-subslance to those in F.I. and F.2!.'-abovc and will not. without the prior written consent of (he City, use any such contractor/subcontractor (ha( does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If Ihe Disclosing Party cannot certify as lo 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.pcrjury, the person signing below: ( I) warrants that he/she is authorized lo execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all ccrtificatiqns and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to (he City.
(Print or lype:name of person signing) Manager
(Print or type title of person signing)
Signed and sworn to before me on (date)
al —Cilice County, lAhftri} (state).
Noiary Public.
ComnMssion expires: jftX^^t^^ \°Pane 12 of 13
I
I
I
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELAT IONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (h) any legal entity which has a direct ownership interest in (he Applicant exceeding 7.5 percent. It is not lo be completed by any legal entity which has only an indirect ownership interest iu the Applicant.
Under Municipal Code Section 2-154t015. the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Parly1' or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as ofthe date Ibis EDS is signed, the Disclosing Party or any "Applicable Part)'" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, die city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law. daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (I) all executive officers ofthe Disclosing Parly listed in Section II.B. I .a., if the Disclosing Party is a corporation; all partners ofthe Disclosing Parly, if the Disclosing Parly is a general partnership; all general partners and limited partners of the Disclosing Party, ifthe Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, ifthe 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 Parly. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes [ft No
If yes, please identify below (I) 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) ihe precise nature of such familial relationship.
Page 13 of 13
CI TY OF CHICAGO ECONOMIC DISCLOSURE S TATEMENT ANI) AFFIDAVIT'
APPENDIX B
BUILDING CODE SCOFFLA W/PROBLEM LANDLORD CERTIFICAT ION
This Appendix is to he completed only by (a) the Applicant, and (b) any legal entity which has '» 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 2-15-1-010. is" the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?
f JYes
Ifthe Applicant.is a legal entiiy 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 2-92-41 Ci of the Municipal Code?
[ J Yes | j No f|Q Not Applicable
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 ofthe building or buildings to which the pertinent .code violations apply
FILLING OU T THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMEN T THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIA TED EDS, AND THAT THE REPRESEN TATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICA TION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OFTHE ASSOCIATED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
Planned development approval for 820-850 W. Lake St. This recertification is being submitted in connection with 200-208 N. Green St., and 201-209 N. Green St. [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants tbat he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date furnished to the City and continue to be true, accurate and complete as ofthe date of this recertification, and (3) reaffirms its acknowledgments.
SD 820 Member LLC
(Print or type legal name of Disclosing Party) By:
(»gh here)
Print or type, name of signatory: Jeffrey Shapack
Title of signatory: Manager
Signed and swom to before me on [date] ~5~<£ ~ I (j? Js-ffrtCj \Vh&Ja££. at fijMK County,.
Notary Public.
Commission expires: OUAJ^. ¦ al 0 ) I ^
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVI T
SECTION I-GENERAL INFORMATION
Legal name of ihe Disclosing Party submitting this EDS. Include d/b/'a/ if applicable:
SP no ffttmb-cr ilu
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[ J the Applicant
OR
jj^ a legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthe
Applicant in which ihe Disclosing Party holds an interest: ^Qjfty\&C$ L-L^(—~>
OR
3. | J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control: :
Business address of the Disclosing Party: E^*? ¦ /*Wyw'V-gu^g ffcllOO
CVUCAgo, XL UOLg.14-
Telephone: Sl2zAb^.QzAQ^ Fax: Email: JSWtpa.cfc^ SWt^tcE CoVft
Name of contact person: J^-ffiVei^ S\^&$OXjC^
Federal Employer Identification No. (if you have one): _
Brief description of contract, transaction or other undertaking (referred to below as the "Matter") lo
which this EDS pertains. (Include project number and location of property, if applicable): ^
^OXkfiM JQZaJ^ki^ '*=>• fcnrt^ASV-- J
Which City agency or department is requesting this EPS? LfcpK of (?)/lYlr/tM^ Qivl $f,\J(\l}^W/fr
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # _ and Contract ii ¦
Page I of 13
SUCTION II - DISCLOSURE OE OWNERSHIP INTERESTS
A. NATURE OI-" Till: DISCLOSING PARTY
1. Indicate the nature ofthe Disclosing Party:,
[' ] Person P>h Limited liability company
| ] Publicly registered business corporation [ ] Limited liability partnership
[ ] Privately held business corporation [] Joint venture
|] Sole proprietorship [] Not-for-profit corporation
f ] General partnership (Is the not-for-profit corporation also a 501(c)(3))?
[ ] Limited partnership [ ] Yes [ j No
[j Trust [] Olher (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
2eJ Q_tC-^±
¦:' - v.* ¦ *¦ .
3. For legal entities not organized in ihe Stale of Illinois: Has the organization registered lo do
business in the Slate of Illinois as a foreign entity?
[ J yes [XJ Ko | ] N/A
B. IE THE DISCLOSING.PARTY IS A LEGAL ENTITY:
1. List below the full names and lilies of all executive officers and all directors of the entity. NOTE: For no i-for-profit corpora I ions, also list below all members, if any, which are legal entities. If there arc no such members, write "no members." For trusts, estates or other similar entities, lisi below the legal tiileho)der(s).
If the entiiy is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, lisi'bclow the name and title of each general partner, managing member, manager or any olher person or entity thai controls the day-to-day management of ihe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
_. Si r_/^A^^4^I__
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interesi (including ownership) in excess of 7.5';-,, uf ihe Disclosing Parly. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Pauc2of 13
interest of a member or manager in a limned liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, slate "None." NOTE.: Pursuant to Section 2-1.54-030 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 Partv
ikupp. x^ccmhSl ulqmJ
SECTION III — BUSINESS RELATIONSHIPS WITH CI TY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-1 56 ofthe Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[ 1 Yes ft
If yes, please identify below the name(s) of such City elected official(s) and describe such rclalionship(s):
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Partv must disclose the name and business address Of each subcontractor, attornev, lobbyist, accountant, consultant and any other person or entiiy whom the Disclosing Party has retained or expects to retain in connection with the Mailer, as well as the nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required lo disclose employees who arc paid solely through the Disclosing Party's regular payroll.
''Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity 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 undertakinsi lo influence anv legislative or administrative action.
Ifthe Disclosing Parly is uncertain whether a disclosure is required under this Section, the Disclosing Parly must either ask the City whether disclosure is required or make the disclosure.
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NO I K:
lo be retained) lobbyist, ele.) "hourly rale"" or "l.b.d." is
noi an acceptable response.
(Add sheets if necessary)
Check here ifthe Disclosing Party has not retained, nor expects lo retain, any such persons or entities. SECTION V--CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under M unicipal 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 ol" competent jurisdiction?
[ ] Yes j)N; No [ ] No person directly or indirectly owns 10% or more of ihe
Disclosing Parly.
If "Yes." has the person'entered'into a court-approved agreement for payment of all support owed and is the person in compliance with thai agreement?
[]Ycs ¦ £]No
FURTHER CERTIFICATIONS
I. Pursuant lo Municipal Code Chapter 1-23, Article I ('•Article l")(which the Applicant should consul! for defined terms (e.g., "doing business") and legal requirements), if (he Disclosing Party submitling (his EDS is the Applicant and is doing business with the City, then ihe Disclosing Partv 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 lo commit bribery, theft, fraud, forgery, perjury, dishonesty or deceir 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, ihe permanent compliance timeframe in Article I supersedes some live-year compliance timeframes in certifications 2 and 3 below.
The Disclosing Parly and. it" the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
are not presently debarred, suspended, proposed lor debarment, declared ineligible or voluntarily excluded from any transactions by any federal, stale 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 lo obtain, or performing a public (federal, slate or local) transaction or contract tinder a public transaction: a violation of federal or stale antitrust statutes;-fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements: or receiving stolen property:
arc not presently indicted for. or criminally or civilly charged by, a governmental entity (federal, sialc or local) with committing any ofthe offenses sel forth in clause B.2.b. of this Section V;
have not. within a five-year period preceding the dale of this EDS, had one or more public transactions (federal, slate or local) terminated for cause or default: and
have not, within a five-year period preceding the dale 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 olher unit of local government
The certifications in subparts 3, 4 and 5 concern:
the Disclosing Parly;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Parly in connection with (he Matter, including but noi limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Olher Retained Parties"'); •
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Parly, is controlled by the Disclosing Parly, or is, with the Disclosing Parly, 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 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 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 ihe Disclosing Parly, any Contractor or any Affiliated Entiiy or any other official, agent or employee of the Disclosing Parly, any Contractor or any Affiliated Entiiy, acting pursuant to ihe direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Neither the Disclosing Party, nor any Conlractor. nor any Affiliated Entity of either the Disclosing Parly or any Contractor nor any Agents have, during the five years before the date this F.DS is signed, or. with respect to a Contractor, an Affiliated Enlit\, or an Affiliated Entiiy of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with ihe .VI alter:
bribed or attempled to bribe, or been convicted or adjudged guilly of bribery or attempting to bribe, a public officer or employee of the City, the Slate of Illinois, or any agency ofthe federal government or of any slate or local government in the United States of America, in thai officer's or employee's official capacity;
agreed or colluded with olher bidders or prospective bidders, or been a parly to any such agreement, or been convicted or adjudged guilly 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 mailer 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, of any of their employees, officials, agents or partners, is barred from contracting with any unit of slate or local government as a result of engaging in or being convicted of (I) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33 E-1: or (3) any similar offense of any stale or ofthe United Slates of America that contains ihe same elements as the offense of bid-rigging or bid-rotaiing.
Neither thc-Disclosing Party norany Affiliated Entity is listed on any ofthe following lists maintained bylhe Office of Foreign Assets Control of ihe U.S. Department ofthe Treasury or the Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Speciallv Designaied Nationals List, the Denied Persons List', the Unverified List, the Entity List and the Debarred Lis!.
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) ofthe •Municipal Code.
Ifthe Disclosing Party is unable to certify to any of ihe above statements in this Pari B (Further Certifications), the Disclosing Party musi explain below:
Page 6 of 1j
Ifthe 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.
tS. To the best ofthe Disclosing Parly's knowledge after reasonable inquiry, the following is a complete lisl of all current employees of ihe Disclosing Paity who w ere, at any lime during the 12-monih period preceding ihe execution date of this L;DS. an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").
9. To the best ofthe Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Parly has given or caused lo be given, at any time during the 1 2-month period preceding ihe execution date of this F.DS. lo an employee, or elected or appointed official, ofthe City of Chicago. For purposes of this/slatemenl. a "gift" docs not include: (i) anything made generally available to City employees or lo the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than S20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION I. The Disclosing Party certifies that the Disclosing Parly (check one)
a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.
2. 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 of ihe 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 ihe City."
Ifthe Disclosing Party is unable to make ibis pledge because it or any of its affiliates (as defined in Section 2-32—155(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):
Ifthe letters "NA." ihe word "None," or no response appears on ihe lines above, ii will be conclusively presumed thai the Disclosing Party certified tu the above statements.
D. CERTIFICATION REGARDING INTER EST IN CITY BUSINESS
Any words or terms thai are defined in Chapter 2-156 ofthe Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-1 56-1 I 0 of the Municipal Code: Docs any official or employee ofthe City have a financial interest in his or her own name or in ihe name of any 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.
Unless sold pursuant lo a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain pow does not constitute a financial interest within the meaning of this Part D.
Does ihe Mailer involve a City Property'Sale?
I I Yes | | No
If you checked "Yes" lo Item D.I provide the names and business addresses of the City officials or employees having such interest and identify ihe 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.
I-. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither 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 lo
Page S of 13
comply with these disclosure rec|uiremenis may make any contract entered into with the City in connection with the Matter voidable by the City.
J__ 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 lo 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 Parly verifies that, as a result of conducting the search in step I above, the
Disclosing Parly has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies thai 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 FENDED MATTERS
NOTE: If (he Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed lo Section VII. For purposes of this Section VI. tax credits allocated by the City and proceeds of debt obligations ofthe 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 Parly with respect to (he Mailer: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or ifthe letters "NA" or ifthe word "None" appear, it will be conclusively presumed thai the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect lo the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds lo 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 lo 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 ofthe 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) ofthe Internal Revenue Code of I 9-Sfi; or (ii) it is an organization described in section
50 l(c)H) of the Internal Revenue Code of 1086 but has not engaged and will not engage in "Lobbying Activities".
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance lo 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 ofthe Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL E\l PLOYMENT OPPORTUNITY
Ifthe Matter is federally funded, federal regulations require the Applicanl.and all proposed subcontractors to submit the following information with their bids or in writing at (he outset of negotiations.
Is the Disclosing Party the Applicant?
[ 1 Yes [JNo If "Yes" answer the three questions below:
Have you developed and do.you have on file affirmative action programs pursuant lo applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes" f ] No
Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes | J No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
| ] Yes f J No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII - ACKNOWLK.DflM KXTS, CONTRACT INCORPORATION. COM PITA \CE, PEN A ETI ES. I) ISCI ,OS Li R E
The Disclosing Parly understands and agrees thai:
The certifications, disclosures, and acknowledgments contained in ihis EDS will become pan of any contract or olher agreement between the Applicant and ihe City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements lo the City's execution of any contract or taking olher action with respect lo ihe Mailer. T he Disclosing Parly understands thai it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign f inancing Ordinances. Chapters 2-156 and 2-164 of ihe Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. T he full text of ihese ordinances and a training program is available on line at w w w .c it vo fc h i e a go. o ru/ Ethics, and.may also be obtained from the City's Board of Ethics. 740 N.
Sedgwick St., Suite 500, Chicago, 11. 60610. (312) 744-9660. The Disclosing Parly 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 submiited 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 Mailer and/or declining to allow the Disclosing Parly lo participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award lo the City of treble damages.
It is the City's policy to make Ihis document.available to ihe public on.its Internet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments lo this EDS may be made available lo Ihe public on the Internet, in response to a Freedom of Information Acl request, or otherwise. By completing and signing ihis EDS, the Disclosing Parly waives and releases any possible rights or claims which it may have against the Cily in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submiited in this EDS.
E. The information provided in this EDS mus! be kepi current. In the event of changes, ihe Disclosing
Parly must supplement this EDS up lo ihe lime the City takes action on ihe Mailer. Ifthe Mailer is a
contract being handled by the City's Department of Procurement Services, the Disclosing Parly must
update this EDS as the contract requires. NOTE: With respect to Mailers subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), ihe 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 thai:
Page 1 I of 13
I'.]. The Disclosing Parly is not delinquent in t he paymenl of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Parly or its Affiliated Entities delinquent in paying any fine, fee. lax or other charge owed to the City. This includes, hut is not limited lo, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 Ifthe Disclosing Party is the'Applicant, the Disclosing Party and its Affiliated Emlitics will not use. nor permit their subcontractors to use. any facility listed by the U.S. E.P.A. on the federal Excluded Parlies List System ("EPFS") maintained by the U. S. General Services Administration.
F.3 Ifthe Disclosing Party is the Applicant: ihe Disclosing Party will obtain from any eoniraemrs/subconlraeiors hired or 10 be hired in connection with the Matter certifications equal in form and substance to those in E.I. and F.2. above and will not. without'the prior written consent of ihe City, use any such contraclor/subeontracior lhai'docs not provide such certifications or thai 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 E. 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 ihis EDS and Appendix A (if applicable) arc true, accurate and complete as of ihe date furnished'lo the Cily.
5 0 /^f^tr/W LLC-
(Print or type name of Disclosing Parly)
Manager
Pace 12 of 13
(Print or type title of person signing)
CITY OK CH ICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WIT H ELECT ED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is (o be completed only by (a) (he Applicant, and (!>) any legal entity which has a direct ownership interest in (he Applicant exceeding 7,5 percent. I( 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 Parly or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if. as ofthe dale ihis EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, ihe city clerk, the city treasurer or any city depariment head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law. son-in:law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of ihe Disclosing Party listed in Section II.B.l.a., ifthe Disclosing Party is a corporation: all partners ofthe Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners of ihe Disclosing Party, if ihe Disclosing Parly is a limited partnership: all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of Ihe Disclosing Party; and (.V) any person having more than a 7.5 percent ownership interest in the Disclosing Parly. " Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Docs the Disclosing Party or any "Applicable Parly" 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 ofthe legal entity to which such person is connected: (3) the name and title ofthe elected city official or department head lo whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE ST ATEMEN T AND AFFIDAVI T
APPENDIX IS
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is lo he completed only by (a) the Applicant, ;md (b) any leg;il entity which lias 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 Miinicipal Codc 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 ofthe Municipal Code? ~
I JYes [j^No
2 If the Applicant is a legal entity publich traded oil am exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?
| J Yes • | ] No iS^Noi Applicable
3. If yes lo (1) or (2) above, please identify below die name ofthe person or legal entity
identified as a building code scofflaw or problem landlord and the address ofthe building or buildings to which the pertinent code v iolations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE IN TO, AND MADE A PART OF, THE ASSOCIATED EDS, ANI) THA T THE REPRESEN TA TIONS MADE IN THIS APPENDIX B -ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIAT ED EDS.
(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose of this page is for you to recertify your EDS prior to submission lo City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)
RECERTIFICATION
Generally, for use with City Council matters. Not for City procurements unless requested.
Zoning map amendment for property located This reccrtification is being submitted in connection with at 838-842 w. Lake St Chicago, Illinois [identify the Matter]. Under penally of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as ofthe date furnished to the City and continue to be true, accurate and complete as ofthe date of this recertification, and (3) reaffirms its acknowledgments.
Parkway Bank & Trust Co.
Trust Number 1950, dated December 12,1984
(Print or type legal name of Disclosing Party)
Print or type name of signatory:
Joseph Maffei
Title of signatory:
Sole Beneficiary of Trust and Holder of Power of Direction
[state].
Notary Public, Slate of Illinois My Commission Expires
LINDSEY RIDGWAY OFFICIAL SEAL
August 20, 2019
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. L .'.indicate the naiurc of die.Disclosihg Pony/ ' ';• ' :"'"v:v<".'H./"' .; ^'V:'|.:^':i;^v;:'^T'
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:;' [ ]. Publicly registered business corporation ' [ J Liniiled liability partnership -V^.' \'[r^ljt^:^^:
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f ]; Other (pleasc'spe'ci'fy)' -1 •'- ' •': • :? :"- • \ ^-y^-. -''\'-•'••?:
£.ihe state,(or foreign couirtf)0'/o'!f ilftol^^ ;.v.\v. -I
U ]; Sole proprietorship ¦¦/ ¦_¦ \; V. •¦¦ [ j:Nbt.Jbr-pV^ -Vy'¦.V"'?"'^:^;^:^
[ ] General partnership -\. ' - • (Is the hot-fdi^rofi^
[ ]; Limited partnership-; ; ; XZl-^^m
^ Trust
- 2;j-/For legal entities
f;3^v-^6"ii J.tiea t?:cn ti I ifcs.^ivof oTg:ania:cd-jin-' the '; businessijn.ihe; Siate pfT
:?v : the legal, lit)eliofder(s). ; ; : . . y ¦"• '/^^CH^T^i
^ >; W die untit>' Is. a general partnership, limited partnership; HihilcdTia^ limited liability^ ,'/".'!.
r: Pnrnw;rship orjo.int venture, list below the name,a'nd title o.fVeaclVg^VaLp^rlnbr; managing.member ¦ ¦¦"'¦
^¦:'-v ¦; manager or any other, person or entity that controls theday-to-day-management oF the DisclosingtParty^ '
|- NO TF: bach legal entiiy listed- bclo\y:musfsubniit an' 'EQS.-bn; iU' oAVn>b'diarft-: ;. ;'. • ¦:'¦/.•';¦'¦ -.' .'.
h- • Name ' ¦ Ti^,6 ,;. ¦>.'¦, .'¦"". •¦ .- "v-¦., ; ill
4.:¦ Stoi^i)^ :iijiL rVvid jm^r- f?,iV4.,::;.:''¦ :^V--,',.'!¦,
' ; ^/.0—3£>^4zhiJksJ^JL.i Sole Beneficiary; :--;y.- \^M~ '^.i
; 2: Please provide the following i„Ibrhration.concerning each person or entity having a direct or" ' indirect beneficial interest (including ownership), in excess of 7.5% Of the. Diselbsing Pa~r«v Example^ of such an interest include shares in a corponuiori, partnership inleresHn a part.krshi^or-toint ventu'f^'
Paue'2 oi: 13.
KoiMkmm^- r*,sonaw*imc,ulcd 10 :,chieve ,u c,,scHw"e-
N— Disc losing. Parry
Code% with any ^ in the '"'"^j^S^ ° y;.^^,. ^ ^T^";<'.v
,,f
' Page3:'of:^:3>::::i ; 'i
re.amcdorant.cipatcd; i '^darc^ ,.,
•¦ not an nc ce ptab)£ re's poiisc.'
H.a.s!any pcrson >vho ajTearagciqiVahyt)
' •"PjscJosing Parly:. ' ' ?y ' ^^¦¦^y^^^:^
US
-nkis:^ ;
c^incsjas^iows: (i) „^&f)^f^-^ bl'S'-^^hc:Giryi dicn the DiscIo^^a^M S ¦
Paw; 4 oK !3
I ! i
2>:-.4fT.hc;Dj sc-1 o.si n g «Pa rty -.a nd, if the Disclosing Party is.a legal-entity, all of,lhose,rjersonsor...entiiics
idcntincd;in,'Scction';II:B.T .
exchided from.any transaction's by. any federal, slate or local 'unit of government; vs-ju,
c.
•^tat£br;jo^ Ft: 2 /iD^p'f'th i s::Sff^ 5^^'.
... ^fia^^ng^
iii'^j.r.ectly^^ 1 jCd ¦by;it^br, \vithHbe Co titractors ^n^ *OpnlTaeipfrpr.;^^
: c6im;'ol;df anptn:er;,|)^ ¦]yM-• '¦%1? S^:'®'^^ i^ "
or any C.ontnictor nor nhy Agents have, diirihguhc five ycars: before the'jatie^t'iiis;E¦^^i,s^^igncd^c5rwf^^J
respect to a Contractor, an Affiliated Entity, or an Affiliated'liniity of a Contractor during me five years:
bef^ withMhc?
Matter:- ¦ ¦ ' .:-vs%;|;a|gg:^
,bnbea;pub!ic.of^
^Urfmedby'the qrace^f^veign AssWC6hlr;df.^ ,,i^u^^r»dust'-y-an^SeluVit^pf the U.S. D.cpari£@^^^ br Ufe'fr&e^ta the Specially^
;JJe|ignatcd Nationals-Lis^he Denied Persons List, the ahVerificci List, the, En'tirybEWand the ¦ ¦ ¦
iD^ba|re;cj List: ^, a?f: "¦' .',v ¦ ¦: /::;4-"y"^ /. .;_¦;,¦:;•>!'-:^'^^^.i:t^-'. r^:'V- y,-0" ^'f^
^j^l^Ff^iFi^TZ>isdlo^ing^Piirt^s"i7rjabIt; to certir^ .
• : ^ expla'in bclo^ 'y , V
Page 6:pi;: i.'3J
If ihe iellcrs "NA," the word "None," or no response appears on the lines above, ii will be conclusively presumed thai the Disclosing Party certified to the above statements.
8. To the best ofthe Disclosing Tarly's knowledge after reasonable inquiry, the following is a complete list ofall current employees ofthe Disclosing Party who were, at any time during the 1 2-month period preceding the execution date of this EDS, an .employee, or elected or appointed official, ; of the City of Chicago {if none, indicate vyith "N/A" or "none").
—— "
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the. following is a complete .list of all gifts that the Disclosing Party has given or caused to;be given,;al.any lime.during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a."gift" docs not include: (i) unylhing made generally available to City employees or to the general public, br(ii) food or drink provided in the course of official City business and having a retail value of less than S20.pcr 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
The Disclosing Party certifies that the Disclosing Party (check one) . ...
[ ] is J^is not
a "financial institution" as defined in Section 2-32—155(b) of the Municipal Code.
If the Disclosing Party IS a financial^ instimtiqn, thbiv (he Disclosing Party pic
"We are not and will not become a predatory lender as defined iii 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 dr becoming an affiliate of a predatory lencler may result in the loss of the privilcgcof doing business with'the City."
Ifthe Disclosing Party is unable to make this pledge because itor 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 ofthe Municipal Code, explain here (attach additional pages if necessary):
- - ¦ ¦ ¦¦ ¦ --^¦tfrflLZ -J —"—~- ——
Page.7 of 13
. . - ¦ ¦ ¦ - ¦ i V>:- - # \-^1^7%^ ^¦¦V^^fr>
jt.ithe letters''N A," die* word "None," or. ho rosp\>hscfa|5;jiea^^^^ be
.c'6.nei\isivelfcpj*^ .;,
.:p;^qBpir^<^«r>rp.N regarding;interesvt^in'cfr^bcjs iness , v„ .>.,,«,,,/,
D.qesUfic^
y^v ;vJLDisctosih g Party further certifies that no prbhibiled financial interest in tlie Maiicr will-^ /,
bcf'acg^ City official or employee. - , '^Q'-l':'''''""' y --rT[':-::- "^rL:-'-;K
•>'\:R'if^seyi?c|ktciiHet5lv:'or- 2-ybclow. Tf lhe*Discldsing';P^ '. • ': '' '
discl6.'.se'b.c^ this BDS-all hifprnYalip^
.¦¦ ' PajicSnf 13••••:V ' • ' ¦ ' / ,;:
comply wiili these disclosure requirements may make any contract entered into, vv.iih the City in e o n n e c t i q n w j ill the". M a 1re r-v oidablo hy the Gity. ;; >\ ¦:«•- ¦;¦;> .,• • • >.¦/. f .. :'X
_M_l. The Disclosing Party verifiesjhat the Disclosing Party has searched^ th>;,DisclpsuigfP;irty and any-and-nil pre.dcccssqremjt.ic^ fx o nrysjayciy ^rjs.lay.ch^ issucdUpv;s'layeliplfe the';'p,j^
_y2.-fT;lrc^
Discipsingjiiarly^ orprofitsTro^ po.liciesi^pie^ the.follpwingfcqiistiW
fecprdsH^ "
r\©iTjE:$f^
fuiijuj^ S ecti^n^ll^Fo^^unji oscs'd f tli i
~. •¦¦¦'V^U V .,. > ....... S • -yiiH J^S^
^anya>erson.jorrCntily.l;listcdpini:Paragraph A.^ v-a ; :p,er.so.n;on;entiDytfoiin:riuencc or,;attcmpt to:;mfli
* ¦'^ij^s^ • K _,. .„,(..T1|.T , vr.,
•'Ya'RplicabJciTeder^
ymenibjer^pf^ with the'award"^^
federal]^ :arnehdf\oi>^
3. Tlic''b'iscjb'siag1. Party \y'iTlas^bn^ir£n'UpdjjSeil certificaupivW
HCh^cr.c:6ccu^'Tanyvevent that"imrterialiy affecis the acctir'ae^'f the statements an'd .infp'rnialibi'i set;
th in'^aTauniplis^ '¦ 'i,
;^JH.^ejy6u
.:;3
e q u a T o p p o r t u n i ly c 1 a ii s e ? ;;'"i'vM
yLI^6U^cjibpl
. Papo 10 of
SECTION VI ( -- JACKNOYVLEDGM ENTS, CONTvRyVCT; JNCO RJ^OJJvypO.N,
COM RLJAN.CE-•j'ENALTIES, DJ.SCEQ.SE'RE : if?;ir^|iy:;j \. ^.,v!;c
The Disclosing Parly understands nhd.v'agvc'c'^ A: The certirications, disc losurcs, a'ndAtekhbwlcdgmc^
''^as^rc^'uircd-^b^Chaptcr JfiJ ;^IEh^v^
I
i
'¦ y (jRriii t for'type name >
j of person-signing): v.^^yy-'v,^
:^;;,;;t-':"
^SrgiieaVa^ (date) , AVfcV^flf I'i)^
Vl'A f fl.^fc' ¦ :' CotintyV / ///V?g7¦ S . .(state):.; -
LINDSEY RIDGiVAY OFFICIAL SEAL
:¦ Q ' :~i%d^-C'£: k".' •:•¦< • y::: Notary^'.lict • > 5$^^'
:!^^ivti-H^oi»'Y.f^brie. Slaio ol.lilinoiii': ,;<*V6?.-wk/6%My'Commission E«p'i>o».V ^^<'<^fi^'^:^.'•ii^.••••Au6^»sl,2.0• 2019 '
¦-¦'y-^y-<'^,-.
' "^.i''l""'. -V.
Pane 12 of 13
I
i
I
I
CITY-OF CHICAGO ECONOMIC DISCLOSURE S TATEMENT AND AM'M-ID/WIT
apVendix A
EAMtLlALR/ELAtlONSEIIPSAVl^^
^'^¦"¦¦¦¦'¦J^ ''''
¦4 m-. ¦'ii^rfsf
ECONOMIC DiSCLOSUK ES;F%EMENT ANl/AF|)l)AV.E'r .
i'jxr" - ^'o,*j^'to:whic11 the per'tiiieiH S.ode:v'ol|tjpife,app^
• ;f'PREFERENCE INTO, AND.-MADE A PART 0F,T1IE ASSOCIATTtD. EDS\ ¥;;>r 14^7'Mi: ¦/Vf?-., ^- ': . v;;ANDTI-IAT THE REPRESENTATIONS^ ADE IN THIS APPENDIX B ARE; v ^V.- ;y,^V
r f 1 : -PERJIIRY ON PAGE 12 6fTOE ASSOC!ATFji El)S#* ' r/; :. yU^^:-00::^M:.
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