ORDINANCE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance is hereby amended by changing all of the B3-2, Community Shopping District symbols as shown on Map No. 2-1 in the area bounded by:
West Lexington Street; South California Avenue; a line 73 feet South of and parallel to West Lexington Street; the public alley next West of and parallel to South California Avenue.
To those of a B2-3, Neighborhood Mixed-Use District
SECTION 2. This Ordinance takes effect after its passage and due publication. Common address of property: 734-736 South California Avenue, Chicago IL.
PLAT OF SURVEY
PARCEL ONE
LOIS 1 AND 2, IN FUELLGKAFF AND PREIS SUBDIVISION OF BLOCK 9, IN GEORGE W CLARKE'S SUBDIVISION OF THE LAST HALF OF THE SOUTHWEST QUARTER OF SECTION 13, TOWNSHIP 39 NORTH, RANGE 13 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS
PARCEL TWO
LOT 3, IN FUELLGRAFF AND PREIS SUBDIVISION OF BLOCK 9, IN GEORGE W. CLARKE'S SUBDIVISION OF THE EAST HALF OF THE SOUTHWEST QUARTER OF SECTION 13, TOWNSHIP 39 NORTH, RANGE 13 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS
16 PUBLIC ALLEY
fence/
0 f NORTH
'FENCE 0 8' NORTH
66 00' R.O.W
OF METAL FENCE
1^
o
CENTER OF CHAIN LINK FENCE-
BUILDING 0 1' NORTH
.FENCE 0 i' NORTH
-38
THREE STORY BRICK BUILDING
#734
NOR1H WALL OF nulLDING RUNS ALONG LOT LINE-
THPEE STORY, BRICK INJILDIMG #740-42
—BUILDING 0 2' NORTH
73.00
SS. CALIFORNIA AVENUE
NOTES
1 SUBJEC1 PROPERTY AREA 8,546 SO FT MORE OR LESS
Urchull and Associates, Inc.
Land Surveying Services
PHONE 700 035 7155 FAX 771 296 9500
Tr'F.nSITE**. urchellnndnaiiocintea coin DESICN TIRU REGISTRATION |1(J4-00«B94
PROPER IY SHOWN HEREON NOT S1AKED, FLAGGED OR MONUMENTED AT THE REQUEST OF THE CLIENT PREPARED FOR: CITYWIDE TITLE CORP.
FIELD WORK COMPLETED. 02/02/16
THIS PROFESSIONAL SERVICE CONFORMS TO THE CURRENT ILLINOIS STANDARDS FOR A BOUNDARY SURVEY.
DATED: 02/02/16
ROBERT J. URCHELL I.P.L.S. No. 3438 LICENSE RENEWAL DATE: NOVEMBER 30. 2016 SURVEY No. 16-01-041
NO IMPROVEMENTS SHOULD BE CONSTRUCTED ON THE BASIS OF THIS PLAT ALONE. FIELD MONUMENTATION OF CRITICAL POINTS SHOULD BE ESTABLISHED PRIOR TO COMMENCEMENT OF CONSTRUCTION.
FOR BUILDING LINE AND OTHER RESTRICTIONS NOT SHOWN HEREON REFER TO YOUR DEED, ABSTRACT, TITLE POLICY, CONTRACTS AND LOCAL BUILDING AND ZONING ORDINANCES.
AFFIDAVIT (Section 17-13-0107)
Date: June 15,2016
Honorable Daniel S. Solis Chairman, Committee on Zoning 121 North LaSalle Street Room 304, City Hall Chicago, Illinois 60602
The undersigned, Zofia Zon 1 being first duly sworn on oath, deposes and states the
following:
The undersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Chicago Zoning Ordinance, by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of public roads, streets, alleys, and other public ways, or a total distance limited to 400 feet. Said written notice was sent by First Class U.S. Mail, no more than 30 days before filling the application
The undersigned certifies that the notice contained the address of the property sought to be rezoned; a statement of the intended use of the property; the name and address of the applicant; the name and address of the owner; and a statement that the applicant intends to file the application for a change in zoning on approximately June 22, 2016.
The undersigned certifies that the applicant has made a bona fide effort to determine the addresses of the parities to be notified under Section 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be served.
Subscribed and Sworn to before
JA32 .AIOhIO
3iOM:-J' *C SUH: • 0\-SU!\ VftATOtf
OMSK) KOI28IMM03 VM
LAW OFFICES MARK J. KUPIEC & ASSOCIATES
SUITE 1801 77 WEST WASHINGTON STREET CHICAGO, ILLINOIS 60602
TELEPHONE (312) 541-1878 FACSIMILE (312) 641 -1745
June 15,2016
Re: 734-736 South California Avenue, Chicago, IL Dear Property Owner:
In accordance with the requirements for an Amendment to the Chicago Zoning Ordinance, specifically Section 17-13-0107, please be informed that on or about June 22, 2016 the undersigned will file an Application for a change in zoning from a B3-2, Community Shopping Zoning District to a B2-3, Neighborhood Mixed-Use Zoning District on behalf of the Applicant, Anna Gutkowska, for the property located at 734-736 South California Avenue, Chicago, Illinois.
The subject property is currently improved with a three-story mixed-use building (2 commercial units on the ground floor and 4 dwelling units on the upper floors). The Applicant needs a zoning change in order to convert the existing commercial units into 2 dwelling units (for a total of 6 dwelling units within the existing building).
The Applicant's address is 5289 North Luna, Chicago IL 60630. The owner of the subject property is Chicago Title Land Trust as Trustee under the Trust Agreement Number 8002370319. Its business address is 10 South LaSalle, Ste. 2750, Chicago IL 60603. I am the Attorney for the Applicant and the contact person for this Application. My address is 77 West Washington Street, Chicago, Illinois, and my telephone number is (312) 541-1878.
Please note that the Applicant is not seeking to rezone or purchase your property. The Applicant is required by law to send this notice because you own property within 250 feet of the property to be rezoned.
Sincerely,
Mark J. Kupiec MJK/ap
City cf Chicago
Department of Housing and Econc nic Development 121 North LaSalle Street - Room 905 Chicago, Illinois 60602
Re: 734-736 South California Avenue, Chicago Dear Sir or Madam:
The undersigned is the sole benefkiary of the CHICAGO TITLE LAND TRUST CO TR # 8002370319, which is the legal tit'? holder of the above mentioned property. Please be advised that Anna Gutkowska is hereby authorized to fde and process an Application for a Zoning Change and any other zon' lg relief in order to convert the existing commercial units into 2 dwelling units (for a tctal of 6 DU) within the existing building at the above address.
Piotr Gutkowski
/BBSS'
CITY OF CHICAGO
APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE
ADDRESS of the property Applicant is seeking to rezone:
734-736 South California Avenue, Chicago
Ward Number that property is located in: 28th Ward
APPLICANT Anna Gutkowska
ADDRESS 5289 N Luna, CITY Chicago
STATE IL ZIP CODE 60630 PHONE 773.865.2141
EMAIL CONTACT PERSON Anna Gutkowska
4. Is the Applicant the owner of the property? YES NO X_
If the Applicant is not the owner cf the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the applicant to proceed.
OWNER CHICAGO TITLE LAND TRUST CO TR # 8002370319
ADDRESS 10 South Lr.Salle, Ste. 2750 CITY Chicago
STATE IL ZIP CODE 60603 PHONE 312.223.4134
EMAIL CONTACT PERSON
5. If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:
ATTORNEY Law Office of Mark J. Kupiec & Assoc.
ADDRESS 77 West Washington St. Ste. 1801
CITY Chicago STATE Illinois ZIP CODE 60602
PHONE 312-541-1878 FAX 312-641-1745 EMAIL aplecka@kupieclaw.com
6. If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners disclosed on the Economic Disclosure Statements.
Piotr Gutkowski (sole beneficiary of the trust)
7. On what date did the owner acquire legal title to the subject property? March 2016
8. Has the present owner previously rezoned this property? If yes, when? NO
Present Zoning District B3-2 Proposed Zoning District B2-3
Lot size in square feet (or dimensions) 73'x 117.07'
Current Use of the property Mixed-use building (2 commercial units on the ground floor and 4 DU
on the upper floors)
Reason for rezoning the property To comply with the minimum lot area in order to
convert the 2 commercial units into 2 dwelling units (for a total of 6 DU within the existing building).
Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)
To convert the existing 2 commercial units into 2 dwelling units within the existing 3-story building
(for a total of 6 DU within the existing building); 6 parking spaces; no commercial space;
existing height - no changes proposed
The Affordable Requirements Ordinance (ARO) 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, 'ncreases 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
COUNTY OF COOK STATE OF ILLINOIS
Anna Gutkowska
. being first duly sworn on oath, states that all of the above
statements and the statements contained in the documents submitted herewith are true and correct.
Subscribed and Sworn to before me this \Cydayof ^c^g, ,20'-6.
ft . . » ^ »
OFFICIAL SEAL KARINA GILARDI Notary Public - State of Illinois My Commission Expires Dec 29, 2018 iff m mgi
For Office Use Only
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
A:.na Gutkowska
Check ONE of the following three boxes:
Indicate whether Disclosing Party submit ting this EDS is:
[x ] the Applicant
OR
[ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which Disclosing Party .holds an interest:
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of Disclosing Party: 5289 N Luna, Chicago IT, 60630
C. Telephone: x: Email:
Name of contact person: Anna Gutkowska
Federal Employer Identification No. ('~you have one): N/A
Brief description of contract, transactkn or other undertaking (referred to below as the" Matter") to which this EDS pertains. (Include projec;: number and location of property, if applicable):
Zoning Change at 734-736 Sou: California Avenue, Chicago
Which City agency or department is requesting this EDS? Dept. of Planning and Development
If the Matter is a contract being handl ed by the City's Department of Procurement Services, please complete the following:
Specification # N/A and Contract # N/A
Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF DISCLOSING PARTY
[x] Person
[ ] Publicly registered business corporation [ ] Privately held business corporation [ ] Sole proprietorship [ ] General partnership [ ] Limited partnership [ ] Trust
[ ] Limited liability company
[ ] Limited liability partnership
[ ] Joint venture
[ ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes [ ] No
[ ] Other (please specify)
2. For legal entities, the state (or foreign
N/A
3. For legal entities not organized in thff business in the State of Illinois as a forei^
[ ] Yes [ ] No
B. IF THE DISCLOSING PARTY IS A
State of Illinois: Has the organization registered to do i entity?
[X] N/A EGAL 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, ?Jso 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 th*? name and title of each general partner, managing member, manager or any other person or entity th?.t controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below m"st submit an EDS on its own behalf.
Name
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal ;Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
N/A
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 [X] No
If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):
N/A
SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose th.^ 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 th ? 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 ether 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
/'
¦'l
Name (indicate whether Business retained or anticipated Address to be retained)
.'Relationship to Disclosing Party Fees (indicate whether
'^subcontractor, attorney, paid or estimated.) NOTE:
lobbyist, etc.) "hourly rate" or "t.b.d" is
not an acceptable response.
Kupiec & Assoc. 77 West Washington St. Ste. 1801
Chicago IL 60602
(Add sheets if necessary)
[ ] Check here if the Disclosing party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-4 .5, substantial owners of business entities that contract with the City must remain in compliance with heir 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 [X] No [ ] No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes," has the person entered into a cc art-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[ ] Yes [ ] No
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I") (which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party Submitting this EDS is the Applicant anc is doing business with the City, then the Disclosing Party Certified as follows: (i) neither the Appfriant nor any controlling person is currently indicted or charged With, or has admitted guilt of, or has eve1 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 acknowledger, 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
i
EDS:
2. 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
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions byj 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 pivil judgment rendered against them in connection with: obtaining, attempting to obtain, oriperforming a public (federal, state or local) transaction or contract under a public transactio;!; 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;
i
have not, within a five-year pericd preceding the date of this EDS, had one or more public
transactions (federal, state or locel) terminated for cause or default; and
j ¦
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
3. The certifications in subparts 3, 4 and 5 concern:
the Disclosing Party; j
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in Connection with the Matter, including out 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; j
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party
or any Contractor nor any Agents have, airing 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: ¦']!¦ ¦
government or of any state or loca or employee's official capacity;
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employed! of the City, the State of Illinois, or any agency of the federal
government in the United States of America, in that officer's
have not been prosecuted for such
d. violated the provisions of Munich
4. Neither the Disclosing Party, Aff' agents or partners, is barred from contrac
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 Ovjlfreedom of competition by agreement to bid a fixed price or otherwise; or j!
made an admission of such conduct described in a. or b. above that is a matter of record, but
conduct; or
al Code Section 2-92-610 (Living Wage Ordinance).
iated Entity or Contractor, or any of their employees, officials, ing with any unit of state or local government as a result of
violation of 720 ILCS 5/33E-4; or (3) any America that contains the same elements
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
similar offense of any state or of the United States of as the offense of bid-rigging or bid-rotating.
Jexplain below:
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with (1) 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 ti> certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party mus'
N/A
Page 6 of 13
-I'-
ll" the letters "NA," the word "None," or rip response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
j
N/A
nth "N/A" or "none").
8. To the best of the Disclosing Party' s! knowledge after reasonable inquiry, the following is a complete list of all current employees of fne Disclosing Party who were, at any time during the 12-month period preceding the execution dads of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate
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 havin|g a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient. N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that t>e Disclosing Party (check one)
[ ] is [X] is not
a "financial institution" as defined in Sec ion 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financic! institution, then the Disclosing Party pledges:
"We are not and will not become a preda'ory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of ou lender as defined in Chapter 2-32 of the I
laffiliates is, and none of them will become, a predatory jlunicipal 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 ithis pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Cede) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A
Page 7 of 13
If the letters "NA," the word "None," or r conclusively presumed that the Disclosing
D. CERTIFICATION REGARDING IN'
Any words or terms that are defined in Ch meanings when used in this Part D.
response appears on the lines above, it will be 3arty certified to the above statements.
jfeREST IN CITY BUSINESS
iipter 2-156 of the Municipal Code have the same
In accordance with Section 2-156 of the City have a financial interest in his entity in the Matter?
[ ] Yes [X] No
NOTE: If you checked "Yes" to Item DA Item D.l., proceed to Part E.
Unless sold pursuant to a process elected official or employee shall have a any other person or entity in the purchase for taxes or assessments, or (iii) is sold b "City Property Sale"). Compensation for does not constitute a financial interest wi
10 of the Municipal Code: Does any official or employee
proceed to Items D.2. and D.3. If you checked "No" to
f competitive bidding, or otherwise permitted, no City nancial interest in his or her own name or in the name of jf any property that (i) belongs to the City, or (ii) is sold jvirtue of legal process at the suit of the City (collectively, roperty taken pursuant to the City's eminent domain power iin the meaning of this Part D,
Does the Matter involve a City Property 2|ale?
[ ] Yes [X] No
3. If you checked "Yes" to Item D. 1 officials or employees having such interest
provide the names and business addresses of the City and identify the nature of such interest:
Nature of Interest
4. The Disclosing Party further certif
s that no prohibited financial interest in the Matter will
be acquired by any City official or employee
E. CERTIFICATION REGARDING SL,
Please check either 1. or 2. below. If tf disclose below or in an attachment to thi's
VERY ERA BUSINESS
s Disclosing Party checks 2., the Disclosing Party must EDS all information required by paragraph 2. Failure to
Page 8 of 13
comply with these disclosure requirements ;may make any contract entered into with the City in connection with the Matter voidable by the City
X 1. The Disclosing Party verifies that *;he 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 thht the following constitutes full disclosure of all such records, including the names of any and ?'l 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 C'.ty are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all perso.'s or entities registered under the federal Lobbying Disclosure Act of 1995 who have made 1'bbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if nece:sary):
(If no explanation appears or begins on tVe lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed hat 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 spe:.t and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph / .1. above for his or her lobbying activities or to pay any person or entity to influence or attempt tc 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 -he award of any federally funded contract, making any federally funded grant or loan, entering i to 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 pi updated certification at the end of each calendar quarter in which there occurs any event that materi&ly affects the accuracy of the statements ar d information set forth in paragraphs A. 1. 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 c> 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 muf" maintain all such subcontractors' certifications for the duration of the Matter and must make sue i certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQ-JAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following inTormation 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:
1. Have you developed and do you hive on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 6^2.)
[]Yes []No '
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Ecual Employment Opportunity Commission all reports due under the applicable filing requirements? j
[ ] Yes [ ] No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause? j
[]Yes []No
If you checked "No" to question 1. or 2. r.bove, 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 Matte, 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 tc 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 Interr et, 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 authorize: the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided here.-- regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
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F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the1 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 Appixant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to us:, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintainec'l by the U.S. General Services Administration.
F.3. If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot ce: ify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached 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 iri this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
Anna Gutkowska
(Print or type name of Diseasing Party)
fjbign here)
Anna Gutkowska (Print or type name of person signing)
n/a
(Print or type title of person signing)
Signed and sworn to before me on (date) .^^CNiP \r> ^ "T7^ \.
at ^C^jr^\^-^ County, C— (state).
OFFICIAL SEAL KARINA GILARDI Notary Public - State of Illinois My Commission Expires Dec 29, 2018
Notary Public.
Commission expires: ^D^^ryK^Z
oITY OF CHICAGO ECEONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT .= APPENDIX A
FAMILIAL RELATIONSHPS WITH ^LETED 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 "App/'cable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, fie 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, grradparent, 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; ?.ll managers, managing members and members of the Disclosing Party, if the Disclosing Party 3 a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person havhg more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" mems 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" --ith an elected city official or department head?
[]Yes [x]No
If yes, please identify below (1) the n-'ne and title of such person, (2) the name c;?the legal entity to which such person is connected; (3) the :ame and title of the elected city official or apartment head to whom such person has a familial relationship, and (4) the precise nat\:re of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or probl em landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ] Yes [x] No
If the Applicant is a legal entity'publicly traded on any exchange, is any officer or director of the Applicant identified as a bvilding code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code? [ ] Yes [ ] No [x] Not Applicable
T ¦
If yes to (1) or (2) above, pleas e identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.
FILLING OUT THIS APPEiVDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND F-'ADE 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.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of Disclosing Party submitting this EDS. Include d/b/a/ if applicable: CHICAGO TITLE LAND TRUST CO TR # 8002370319
Check ONE of the following three boxes:
Indicate whether Disclosing Party submitting this EDS is:
[x] the Applicant
OR
[ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which Disclosing Party holds an interest:
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of Disclosing Party: 10 South LaSalle, Ste. 2750, Chicago IL 60603
Telephone: 312.223.4134 Fax: Email:
Name of contact person: Kelli A. Beyer- Wyzykowski
Federal Employer Identification No. (if you have one): N/A
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 Change at 734-736 South California Avenue, Chicago
Which City agency or department is requesting this EDS? Dept. of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # N/A \ and Contract # N/A
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SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF DISCLOSING PARTY
[ ] Limited liability company [ ] Limited liability partnership [ ] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?
] Limited partnership x] Trust
1. Indicate the nature of the Disclosing Party: ] Person [ ] Publicly registered business corporation [ ] Privately held business corporation [ ] Sole proprietorship [ ] General partnership (.
[ ] Yes [ ] No
[ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
11
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?
[X] N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title Chicago Title Land Trust Company Trustee
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
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interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 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
Piotr Gutkowski, 5289 N Luna, Chicago IL 60630 100%
SECTION III - - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes [X] No
If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):
SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.
"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.
n/a ¦
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Name (indicate whether Business ¦ Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) ' lobbyist, etc.) "hourly rate" or "t.b.d" is
not an acceptable response.
Kupiec & Assoc. 77 West Washington St. Ste. 1801 Attorneys $4,500 (estimated)
Chicago IL 60602
(Add sheets if necessary)
[ ] Check here if the Disclosing party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] 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
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I") (which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party Submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party Certified 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 I I.B.I, 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
e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty,
or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning
environmental violations, instituted by the City or by the federal government, any state, or any
other unit of local government.
The certifications in subparts 3, 4 and 5 concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in Connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during 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 A ffiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with (1) the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
Page 6 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient. N/A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is [X] is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A
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If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ] Yes [X] No
NOTE: If you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. If you checked "No" to Item D.L, proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes [X] 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
X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of
the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery, or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A.l. above for his or her lobbying activities or to pay any person or entity to influence or attempt to in fluence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A. l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No
If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment 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:
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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 Matte, whether Procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
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F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2. If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U.S. General Services Administration.
F.3. If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
CHICAGO TITLE LAND TRUST CO TR # 8002370319
(Print or type name of Disclosing Party)
The information contained b this curtlfleatlort ha* been furnished to tha J«ndtruitsa.by the beneficiariesofmi«tno. OfiOZWffllandthe certification is maoto solely in reliance thereon and no responsibility it assumed by the trustee In Its Individual CMicitv, for the truth or iceuraey of thc>uv.t therein stated.
Signed and sworn to before me on (date) ipj 10 / lift
This instrument is executed by the undersigned Land Trustee, not personally but solely as Trustee in the exercise of the power and authority conferred upon and vested in it as such Trustee. It is expressly understood and agreed that all the warranties, indemnities, representations, covenants, undertakings and agreements herein made on the part of the Trustee are undertaken by it solely in its capacity as Trustee and not personally. No personal liability
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Commission expires:
CITY OF CHICAGO ECEONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHPS WITH ELETED 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 [x]No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROULEM 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.
Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ] Yes [x] 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?
[ ] Yes [ ] No [x] 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 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.