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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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Lease agreement with Chicago Title Land Trust, solely as trustee for beneficiary Irving Sterling Venture LLC for premises at 3542-3552 W Irving Park Rd for use by Chicago Public Library
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Topic:
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AGREEMENTS - Lease
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Attachments:
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1. O2016-6085.pdf
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OFFICE OF THE MAYOR CITY OF CHICAGO RAHM EMANUEL MAYOR July 20, 2016 TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO Ladies and Gentlemen: At the request of the Commissioner of Fleet and Facility Management, I transmit herewith ordinances authorizing the execution of lease agreements. Your favorable consideration of these ordinances will be appreciated. Mayor Very truly yours, ORDINANCE BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1: On behalf of the City of Chicago as Tenant, the Commissioner of the Department of Fleet and Facility Management is authorized to execute a Lease with Chicago Title Land Trust as trustee and Irving Sterling Venture, LLC as beneficiary under Trust Number 132968, collectively as Landlord, for use of approximately 11,700 square feet of building space located at 3542-3552 West Irving Park Road by the Chicago Public Library as the Independence Branch Library; such Lease to be approved by the Commissioner of the Chicago Public Library, the President of the Chicago Public Library Board of Directors, and approved as to form and legality by the Corporation Counsel in substantially the following form: LEASE NO. 19007 LEASE THIS LEASE is made and entered as of the day of 2016, by and between IRVING STERLING VENTURE LLC, an Illinois limited liability company ("Irving"), CHICAGO TITLE LAND TRUST COMPANY not personally but solely as Trustee under a Trust Agreement dated March 28, 2005 and known as Trust Number 132968 ("Land Trust") and the CITY OF CHICAGO, an Illinois municipal corporation and home rule unit of local government (hereinafter referred to as "Tenant" or "City"). RECITALS WHEREAS, Land Trust is the owner of the real property more commonly known as 3530-58 West Irving Park Road, Chicago, Cook County, Illinois ( "Irving Plaza"); and WHEREAS, Irving is the beneficiary of Land Trust; and WHEREAS, Irving and Land Trust are collectively referred to in this Lease as "Landlord"; and WHEREAS, Tenant leased and occupied approximately 8,888 square feet of ground floor space located in Irving Plaza under a prior lease with Landlord dated August 28lh, 2013 (the "2013 Lease") for use as the Independence Branch of the Chicago Public Library; and WHEREAS, on October 30, 2015, a fire occurred in Irving Plaza in the unit adjacent to the leased premises, and the leased premises suffered smoke, soot, and water damage; and WHEREAS, after the fire, the Landlord renovated the leased premises and Tenant resumed occupancy on [DATE TBD], 2016; and WHEREAS, Landlord and Tenant wish to expand the leased premises and enter into this new Lease. NOW THEREFORE, in consideration of the covenants, terms and conditions set forth herein, the parties hereto agree and covenant as follows: SECTION 1. GRANT Landlord hereby leases to Tenant the following described premises situated in the City of Chicago, County of Cook, State of Illinois, to wit: Approximately 11,700 square feet of ground floor space (the "Premises") in Irving Plaza. The address for the Premises is 3542-3552 West Irving Park Road, Chicago, Illinois. The location of the Premises is cross-hatched in black on the drawing attached hereto and made a part hereof as Exhibit A. Irving Plaza is located on PIN 13-14-424-031-0000. |1010| LEASE NO. 19007 Tenant shall have shared access to the parking lot in the rear of Irving Plaza on a first come, first served basis. The parking lot is located at 4014-4016 North Drake Avenue, PIN 13-14-424-032. SECTION 2. TERM The term of this Lease ("Term") shall commence on January 1, 2017 ("Commencement Date") and shall end on December 31, 2023 unless sooner terminated as set forth in this Lease. SECTION 3. RENT, TAXES, AND UTILITIES Base Rent. Tenant shall pay Landlord base rent for the Premises in the amount of: Twenty-One Thousand Four Hundred Fifty and 00/100 Dollars ($21,450.00) per month for the period beginning on January 1, 2017 and ending on December 31, 2017; Twenty-One Thousand Nine Hundred Eighty-Six and 25/100 Dollars ($21,986.25) per month for the period beginning on January 1, 2018 and ending on December 31, 2018; Twenty-Two Thousand Five Hundred Thirty-Five and 91/100 Dollars ($22,535.91) per month for the period beginning on January 1, 2019 and ending on December 31, 2019; and Twenty-Three Thousand Ninety-Nine and 30/100 Dollars ($23,099.30) per month for the period beginning on January 1, 2020 and ending on December 31, 2020; and Twenty-Three Thousand Six Hundred Seventy-Six and 79/100 Dollars ($23,676.79) per month for the period beginning on January 1, 2021 and ending on December 31, 2021; and Twenty-Four Thousand Two Hundred Sixty-Eight and 71/100 Dollars ($24,268.71) per month for the period beginning on January 1, 2022 and ending on December 31, 2022; and Twenty-Four Thousand Eight Hundred Seventy-Five dollars and 42/100 ($24,875.42) per month for the period beginning on January 1, 2023 and ending on December 31, 2023. Rent shall be paid monthly in advance to Irving Sterling Venture LLC at 2701 West Peterson Avenue, Chicago, Illinois 60659-3995, or at such place and to such payee as Irving may from time to time designate in writing to Tenant. Taxes and Other Levies. Subject to Tenant's reimbursement obligations as outlined below in Paragraph 3.3 (c), Landlord shall pay when due all real estate taxes, special assessments, and other levies assessed by government authorities against the Premises, except for those charges which this Lease specifies that Tenant shall pay. LEASE NO. 19007 Reimbursement of Costs. In addition to the base rent set forth in Paragraph 3.1 above of this Lease, Tenant shall pay to Landlord upon Landlord's request from time to time after the commencement of the term of this Lease: Seventy Eight Percent (78%) of the amount paid by Landlord for cleaning, lighting and snowplowing the sidewalk around the Premises, alley, as well as the adjoining parking areas. One Hundred Percent (100%) of the amount paid by Landlord to the City of Chicago and/or any other authority for water and sewer services supplied to the Premises as measured by the submeter on the Premises. Seventy Eight Percent (78%) of the amount by which the real estate taxes levied or assessed for each calendar year partly or wholly within the term of this Lease against Irving Plaza exceed the real estate taxes for Irving Plaza for the calendar year 1994, payable in 1995, except that in the event Tenant or Landlord terminate this Lease pursuant to Paragraph 7.1 or Paragraph 10.10 of this Lease, such amount levied for the calendar year in which the last date of this Lease occurs shall be pro-rated based on the number of months during the year in which the termination occurred. Each request by Landlord for a payment pursuant to the foregoing provisions of this Section 3.3 shall be accompanied by reasonable documentation to support the payment request by Landlord. In addition, any request by Landlord for a real estate tax reimbursement pursuant to the foregoing subparagraph (c) with respect to any year after 1994 shall be made by Landlord to Tenant within ninety (90) days after the payment by Landlord of the second installment real estate tax bill for the Premises for such year after 1994. Utilities. Tenant shall pay when due all charges for electricity, light, gas, heat, power, telephone or other communication service, and all other utility services used in or supplied to the Premises, except for those charges which this Lease specifies that Landlord shall pay. SECTION 4. CONDITION AND ENJOYMENT OF PREMISES, ALTERATIONS AND ADDITIONS, AND SURRENDER Condition of Premises Upon Delivery of Possession. Landlord covenants that, as of the Commencement Date, the Premises are in compliance with all laws, ordinances and regulations of all federal, state and municipal governmental authority which are applicable to the Premises. Covenant of Quiet Enjoyment. Landlord covenants and agrees that Tenant, upon paying the rent and upon observing and keeping the covenants, agreements and conditions of this Lease on its part to be kept, observed and performed, shall lawfully and quietly hold, occupy and enjoy the Premises (subject to the provisions of this Lease) during the Term without hindrance or molestation by Landlord or by any person or persons claiming under Landlord. |1010| LEASE NO. 19007 Landlord's Duty to Maintain Premises and Right of Access. If Landlord shall fail * to perform any of Landlord's obligations under Section 11 of this Lease within ten (10) business days after written notice of such failure is given by Tenant to Landlord unless such obligation cannot be remedied within such ten (10) business days and Landlord shall have commenced and is diligently pursuing all necessary action to perform such obligation, Tenant is then authorized to perform such obligation which Landlord has failed to perform and Landlord will promptly, and within ten (10) business days of demand, reimburse Tenant for the reasonable cost thereof. Landlord shall have the right of access to the Premises for the purpose of inspecting and performing such obligations, provided that except in the case of emergencies, Landlord shall first give notice to Tenant of Landlord's desire to enter the Premises and Landlord will schedule its entry so as to minimize to the extent reasonably practicable any interference with Tenant's use of the Premises. Use of the Premises. Tenant shall use the Premises as the Independence Branch of the Chicago Public Library or any other suitable municipal use. Tenant shall not use the Premises in a manner that would violate any law. Tenant further covenants (a) not to do or suffer any waste or damage, (b) to comply in all respects with the laws, ordinances, orders, rules, regulations, and requirements of all federal, state and municipal governmental departments which may be applicable to the Premises or to the use or manner of use of the Premises, and (c) not to perform or permit disfigurement or injury to any building or improvement on the Premises, or to fixtures and equipment thereof. Alterations and Additions. Tenant shall have the right to make such alterations, additions, and improvements in the Premises at Tenant's cost and expense as Tenant shall deem, necessary, provided that any such alterations, additions, and improvements shall be in full compliance with the applicable law and shall not be structural in nature. In addition. Tenant must secure Landlord's prior written consent with respect to said alterations, additions, and improvements prior to performing any of said alterations, additions, and improvements. SECTION 5. ASSIGNMENT, SUBLEASE, AND LIENS Assignment and Sublease. Tenant shall not assign this Lease in whole or in part, or sublet the Premises or any part thereof without the prior written consent of Landlord in each instance. Landlord shall not unreasonably withhold its consent to any such subletting or assignment. Tenant's Covenant Against Liens. Tenant shall not cause or permit any lien or encumbrance, whether created by act of Tenant, operation of law or otherwise, to attach to or be placed upon Landlord's title or interest in the Premises. All liens and encumbrances created by Tenant shall attach to Tenant's interest only. SECTION 6. INSURANCE AND INDEMNIFICATION 6.1 Insurance. The Landlord shall procure and maintain at all times, at Landlord's own expense, during the term of this Lease, the insurance coverages and requirements specified below. |1010| LEASE NO. 19007 The kinds and amounts of insurance required are as follows: Workers Compensation and Employers Liability Insurance. Workers Compensation and Employers Liability Insurance, in accordance with the laws of the State of Illinois-covering all Landlord's employees and Employer's Liability coverage with limits of not less than $100.000 for each accident or illness in connection with work performed by Landlord. Commercial Liability Insurance. (Primary and Umbrella). Commercial Liability Insurance or equivalent with limits of not less than $2,000.000 per occurrence, for bodily injury, personal injury, and property damage liability. The City of Chicago is to be named as additional insureds on a primary, non contributory basis for any liability arising directly or indirectly from this Lease. Automobile Liability Insurance. (Primary and Umbrella). When any motor vehicles (owned, non-owned and hired) are used in connection with work to be performed by Landlord, the Landlord shall provide Comprehensive Automobile Liability Insurance with limits of not less than $1,000,000 per occurrence, for bodily injury and property damage caused by such vehicles. Property Insurance. Property insurance coverage shall be maintained by the Landlord for full replacement value covering the building in which the Premises is located to protect against loss, damage to or destruction of such building. The Landlord shall be responsible for all loss or damage to personal property (including but not limited to materials, equipment, tools and supplies), owned or rented, by the Landlord. 6.2 Other Terms of Insurance. Within thirty (30) days after receipt of written request from Tenant, the Landlord will furnish the'City of Chicago, Department of Fleet and Facility Management, Office of Real Estate Management, 30 North LaSalle Street, Suite 300, Chicago, Illinois 60602, a Certificate of Insurance evidencing the required coverage to be in force on the date of this Lease. The Landlord shall submit evidence on insurance prior to the commencement of the Term. The receipt of any certificates does not constitute agreement by the City that the insurance requirements in the Lease have been fully met or that the insurance polices indicated on the certificate are in compliance with all Lease requirements. The failure ofthe City to obtain certificates or other insurance evidence from Landlord shall not be deemed to be a waiver by the City. Non-conforming insurance shall not relieve Landlord of its obligation to provide Insurance as specified herein. Nonfulfillment of the insurance conditions may constitute a violation of the Lease. The Insurance shall provide that should any of the applicable policies be canceled before the expiration date thereof, the issuing insurer will endeavor to mail 60 days prior written notice to be given to the City in the event coverage is substantially changed, canceled, or non-renewed but failure to do so shall impose no obligation or liability of any kind upon the insurer, its agents or representatives. |1010| LEASE NO. 19007 Any and all deductibles or self insured retentions on referenced insurance coverages shall be borne by Landlord. The Landlord agrees that Landlord shall waive the right of subrogation against the City of Chicago. The Landlord expressly understands and agrees that any coverages and limits furnished by Landlord shall in no way limit the Landlord's liabilities and responsibilities specified within the Lease documents or by law. The Landlord expressly understands and agrees that any insurance or self insurance programs maintained by the City of Chicago shall apply in excess of and not contribute with insurance provided by the Landlord under the lease. The required insurance shall not be limited by any limitations expressed in the indemnification language herein or any limitation placed on the indemnity therein given as a matter of law. 6.3 Landlord's Indemnification. Landlord shall indemnify and hold Tenant harmless against all liabilities, judgment costs, damages, and expenses which may accrue against, be charged to, or be recovered from Tenant by reason of Landlord's negligent performance of or failure to perform any of its obligations under this Lease. SECTION 7. DAMAGE OR DESTRUCTION 7.1 Damage or Destruction. If the Premises is damaged or destroyed by fire or other casualty or event to such extent that Tenant cannot continue occupancy or conduct its normal business therein, and if such damage or destruction is not repaired by Landlord or Tenant within ninety (90) days after the occurrence of such damage or destruction, then Tenant or Landlord shall have the option within one hundred (100) days after the occurrence of such damage or destruction to declare this Lease terminated as of the date of such damage or destruction by giving the other party written notice to such effect. If Tenant or Landlord exercises this option, the rent shall be apportioned as of the date of such damage or destruction and Landlord shall forthwith repay to Tenant all prepaid rent. In any event, rent payable by Tenant under this Lease shall abate during the period the Premises are rendered untenantable by such damage or destruction in proportion to- the number of square feet of floor space in the Premises that are untenantable as the result of such fire or other casualty. SECTION 8. CONFLICT OF INTEREST AND GOVERNMENTAL ETHICS 8.1 Conflict of Interest. No official or employee of the City of Chicago, nor any member of any board, commission or agency ofthe City of Chicago, shall have any financial interest, (as directed in Chapter 2-156 of the Municipal Code of Chicago), either direct or indirect, in the Premises; nor shall any such official, employee, or member participate in making or in any way attempt to use his/her position to influence any City governmental decision or action with respect to this Lease. |1010| LEASE NO. 19007 8.2 Duty to Comply with Governmental Ethics Ordinance. Landlord and Tenant shall comply with Chapter 2-156 of the Municipal Code of Chicago, "Governmental Ethics," including but not limited to section 2-156-120, which states that no payment, gratuity, or offer of employment shall be made in connection with any City ofChicago contract as an inducement for the award of that contract or order. Any contract negotiated, entered into, or performed in violation of any ofthe provisions of Chapter 2-156 shall be voidable as to the City ofChicago. SECTION 9. HOLDING OVER 9.1 Holding Over. Any holding over by Tenant shall be construed to be a tenancy from month to month only beginning on the date the Term ends and the base monthly rent shall be at the same rate as set forth in Section 3.1 (g) of this Lease. During any holding over period, Tenant shall also be responsible for the Reimbursement of Costs as set forth in Section 3.3 of this Lease and any other amounts payable by Tenant under this Lease. SECTION 10. MISCELLANEOUS 10.1 Notice. All notices, demands and requests which may be or are required to be given, demanded or requested by either party to the other shall be in writing. All notices, demands and requests by Landlord to Tenant shall be delivered by national overnight courier or shall be sent by United States registered or certified mail, return receipt requested, postage prepaid addressed to Tenant as follows: City of Chicago Department of Fleet and Facility Management Office of Real Estate Management 30 North LaSalle - Suite 300 Chicago, Illinois 60602 or at such other place as Tenant may from time to time designate by written notice to Landlord and to Tenant at the Premises. All notices, demands, and requests by Tenant to Landlord shall be delivered by a national overnight courier or shall be sent by United States registered or certified mail, return receipt requested, postage prepaid, addressed to Landlord as follows: Irving Sterling Venture LLC 2701 West Peterson Avenue Chicago, Illinois 60659-3995 Attn: Mr. Franklin L. Friedman or at such other place as Landlord may from time to time designate by written notice to Tenant. Any notice, demand or request which shall be served upon Landlord by Tenant, or upon Tenant by Landlord, in the manner aforesaid, shall be deemed to be sufficiently served or given for all purposes hereunder at the time such notice, demand or request shall be mailed. |1010| LEASE NO. 19007 Partial Invalidity. If any covenant, condition, provision, term or agreement of this Lease shall, to any extent, be held invalid or unenforceable, the remaining covenants, conditions, provisions, terms and agreements of this Lease shall not be affected thereby, but each covenant, condition, provision, term or agreement of this Lease shall be valid and in force to the fullest extent permitted by law. Governing Law. This Lease shall be construed and be enforceable in accordance with the laws of the State of Illinois, without regard to conflicts of law principles. Entire Agreement. All preliminary and contemporaneous negotiations are merged into and incorporated in this Lease. This Lease contains the entire agreement between the parties and shall not be modified or amended in any manner except by an instrument in writing signed by the Landlord and Tenant. Captions and Section Numbers. The captions and section numbers appearing in this Lease are inserted only as a matter of convenience and in no way define, limit, construe or describe the scope or intent of such sections of this Lease nor in any way affect this Lease. Binding Effect of Lease. The covenants, agreements, and obligations contained in this Lease shall extend to, bind, and inure to the benefit of the parties hereto and their legal representatives, heirs, successors, and assigns. Time is of the Essence. Time is ofthe essence of this Lease and of each and every provision hereof. No Principal/Agent or Partnership Relationship. Nothing contained in this Lease shall be deemed or construed by the parties hereto or by any third party as creating the relationship of principal and agent or of partnership or of joint venture between the parties hereto. Authorization to Execute Lease. The parties signing this Lease hereby represent and warrant that they are the duly authorized and acting representatives of Landlord and Tenant respectively and that by their signing of this Lease it became the binding obligation of Landlord and Tenant respectively, subject to no contingencies or conditions except as specifically provided herein. Termination of Lease. Tenant shall have the right to terminate this Lease by providing the Landlord with one hundred eighty days (180) prior written notice any time after December 31, 2018. If Tenant exercises this termination right, Tenant shall reimburse Landlord one eighty-fourth (1 /84th) of the Build Out Costs, as defined in Exhibit C, capped at a total of Three Hundred Thousand Dollars ($300,000), for each month remaining on the Term of the Lease. Force Majeure. When a period of time is provided in this Lease for either party to do or perform any act or thing, the party shall not be liable or responsible for any delays due to strikes, lockouts, casualties, acts of God, wars, governmental regulation or control, and other S LEASE NO. 19007 causes beyond the reasonable control of the party, and in any such event the time period shall be extended for the amount of time the party is so delayed. Condemnation. If the whole or any substantial part of the Premises are taken or condemned by any competent authority for any public use or purpose, or if any adjacent property or street shall be so condemned or improved in such a manner as to require the use of any part of the Premises, the term of this Lease shall, at the option of Landlord or the condemning authority, be terminated upon, and not before, the date when possession of the part so taken shall be required for such use or purpose, and Landlord shall be entitled to receive the entire award without apportionment with Tenant. Rent shall be apportioned as of the date of Tenant's vacating as the result of said termination. No Broker. Tenant warrants to Landlord that no broker or finder (a) introduced Tenant to the Premises, Irving or Franklin L. Friedman, (b) assisted Tenant in the negotiation of this Lease, or (c) dealt with Tenant on Tenant's behalf in connection with the Premises or this Lease. Landlord warrants to Tenant that, except for Franklin L. Friedman, no broker or finder (a) introduced Landlord to Tenant, (b) assisted Landlord in the negotiation of this Lease, or (c) dealt with Landlord on Landlord's behalf in connection with the Premises or this Lease. Landlord hereby discloses to Tenant that Franklin L. Friedman has a financial interest in Landlord, is a licensed Illinois real estate broker, and is not claiming any commission as a result of this Lease. 10.14 Prior Lease. Landlord and Tenant acknowledge and agree that the Tenant has leased a portion of the Premises under the 2013 Lease. Landlord and Tenant each acknowledge and agree that that the other party has performed all obligations under the 2013 Lease and that neither party has any claims against the other with respect to the 2013 Lease. SECTION 11. ADDITIONAL RESPONSIBILITIES OF LANDLORD Landlord's Responsibilities. Landlord shall perform the following (subject to the provisions of Paragraph 11.2 of this Lease): Provide water to the Premises; Provide any required maintenance to the foundation and brick portions (other than doors and windows) of the exterior masonry structural walls of the Premises and repair any leak in the roof of the Premises; and Clean the sidewalk in front ofthe Premises to the same extent that Landlord provides such service to the other tenants in Irving Plaza. Qualifications. Notwithstanding anything to the contrary set forth in the preceding Paragraph 11.1 of this Lease: |10 10| LEASE NO. 19007 Landlord shall only be required to perform any of Landlord's obligations pursuant to the preceding Paragraph 11.1 of this Lease within a reasonable period of time (considering Acts of God and other occurrences beyond Landlord's control) after Landlord receives from Tenant written notice identifying the need for the performance of such obligation; Landlord shall only be required to perform such exterior obligations if the exterior weather conditions are conducive for the performance of such obligation; Landlord shall only be required to perform such obligation if the need for the performance of such obligation is not caused by any act or neglect of Tenant or any of Tenant's employees, contractors, agents, representatives, invitees or any person or entity holding by, through or under Tenant; and Landlord shall not be liable to Tenant for any damage to any property of Tenant or for any loss of business in or use of the Premises caused by the need for the performance by Landlord of any obligation. 11.3 Build Out. Prior to the Commencement Date, the Landlord will have completed the repair and build out of the Premises as agreed to between Landlord and Tenant, and as further described in Exhibit B attached hereto. SECTION 12. ADDITIONAL RESPONSIBILITIES OF TENANT 12.1 Tenant's Responsibilities. Tenant, at Tenant's cost and expense, shall at all times during the term of this Lease: Replace any broken glass on, in or about the Premises (including glass in any walls, doors and windows) provided that said damage was not caused by Landlord or Landlord's employees or attributable to Landlord negligence or Landlord's employee's negligence; Provide nightly custodial services for the Premises which shall be construed as cleaning, scavenger, exterminator, window and other washing, emptying wastepaper baskets, replacement of light bulbs and tubes and lighting ballasts and sweeping of any kind; Maintain and repair in operating condition the Premises and. all parts thereof, including without limitation the heating, air-conditioning, lighting, electrical, plumbing and other equipment, fixtures, parts and/or systems in or for the Premises (except for Landlord's obligations under Section 11 of this Lease); Upon the termination of this Lease, surrender the Premises to Landlord in a comparable condition that existed at the Premises as of the Commencement Date, with normal wear and tear taken into consideration; Allow Landlord to place upon the Premises rental signs each not to exceed 2 feet square in size; 10 LEASE NO. 19007 Provide monthly alarm service, if determined to be necessary by Tenant; Not perform or permit any practice than may (i) damage the reputation of, or otherwise be injurious to, the Premises or neighborhood, or (ii) be disturbing to other tenants, or (iii) be illegal, or (iv) increase the rate of insurance on the Premises; and Keep out of the Premises materials which cause a fire hazard or safety hazard; Comply with reasonable requirements of Landlords' fire insurance carrier; Not destroy, deface, damage, impair, or remove any part of the Premises or facilities, equipment or appurtenances thereto; and Maintain any smoke detectors in the Premises in accordance with applicable law. SECTION 13. ADDITIONAL CLAUSES Lease Supremacy. Landlord and Tenant acknowledge that except as expressly set forth in this Lease, this Lease supersedes any prior leases for the Premises between Tenant and Landlord or Landlord's predecessor-in-interest. Except as expressly set forth in this Lease, the prior leases are null and void and of no further force or effect. Non-disturbance and Attornment Agreement. In the event that the Premises are subject to a mortgage as of the date of this Lease, a non-disturbance and attornment agreement will be obtained from any mortgagee(s) at that time. Closure of Library. Landlord, at Landlord's option may (but shall not be obligated to) perform maintenance and/or other work from time to time during the term of this Lease to the front masonry wall of the building in which the Premises is located. If Landlord delivers two weeks prior written notice to Tenant requesting that Tenant close the library during the period in which Landlord is performing such work, Tenant (at Tenant's cost and expense) shall close the library during such period. If Landlord so notifies Tenant in writing that Landlord is requiring Tenant to so close the library, the base rent payable under this Lease shall abate during such period that Landlord requires Tenant to so close. SECTION 14. DISCLOSURES AND REPRESENTATIONS 14.1 Business Relationships. Landlord acknowledges (a) receipt of a copy of Section 2-156-030 (b) of the Municipal Code of Chicago, (b) that it has read such provision and understands that pursuant to such Section 2-156-030 (b) it is illegal for any elected official of the City, or any person acting at the direction of such official, to contact, either orally or in writing, any other City official or employee with respect to any matter involving any person with whom the elected City official or employee has a "Business Relationship" (as defined in Section 2-156-080 of the Municipal Code of Chicago), or to participate in any discussion in any City Council committee hearing or in any City Council meeting or to vote on any matter involving the person with whom an elected official has a Business Relationship, and (c) notwithstanding anything to the contrary contained in this Lease, that a violation of Section 2-156-030 (b) by an elected official, or any person acting at the direction of such official, with respect to any transaction 11 LEASE NO. 19007 contemplated by this Lease shall be grounds for termination of this Lease and the transactions contemplated hereby. Landlord hereby represents and warrants that no violation by Landlord of Section 2-145-030 (b) has occurred with respect to this Lease or the transactions contemplated hereby. Patriot Act Certification. Landlord represents and warrants that neither Landlord nor, to the best of Landlord's knowledge, any Affiliate (as hereafter defined) thereof is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury, the Bureau of Industry and Security of the U.S. Department of Commerce or their successors, or on any other list of persons or entities with which the City may not do business under any applicable Laws: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List. As used in this Section, an "Affiliate" shall be deemed to be a person or entity related to Landlord that, directly or indirectly, through one or more intermediaries, controls, is controlled by or is under common control with Landlord, and a person or entity shall be deemed to be controlled by another person or entity, if controlled in any manner whatsoever that results in control in fact by that other person or entity (or that other person or entity and any persons or entities with whom that other person or entity is acting jointly or in concert), whether directly or indirectly and whether through share ownership, a trust, a contract or otherwise. Prohibition on Certain Contributions-Mayoral Executive Order No. 2011-4. Landlord agrees that Landlord, any person or entity who directly or indirectly has an ownership or beneficial interest in Landlord of more than 7.5 percent ("Owners"), spouses and domestic partners of such Owners, Landlord's contractors (i.e., any person or entity in direct contractual privity with Landlord regarding the subject matter of this Lease) ("Contractors"), any person or entity who directly or indirectly has an ownership or beneficial interest in any Contractor of more than 7.5 percent ("Sub-owners") and spouses and domestic partners of such Sub-owners (Landlord and all the other preceding classes of persons and entities are together the "Identified Parties"), shall not make a contribution of any amount to the Mayor of the City of Chicago (the "Mayor") or to his political fundraising committee (a) after execution of this Lease by Landlord, (b) while this Lease or any Other Contract (as hereinafter defined) is executory, (c) during the term of this Lease or any Other Contract, or (d) during any period while an extension of this Lease or any Other Contract is being sought or negotiated. This provision shall not apply to contributions made prior to May 16, 2011, the effective date of Executive Order 2011-4. Landlord represents and warrants that to the best of Landlord's knowledge from the later of (a) May 16, 2011, or (b) the date the City approached Landlord, or the date Landlord approached the City, as applicable, regarding the formulation of this Lease, no Identified Parties have made a contribution of any amount to the Mayor or to his political fundraising committee. Landlord agrees that it shall not: (a) coerce, compel or intimidate its employees to make a contribution of any amount to the Mayor or to the Mayor's political fundraising committee; (b) reimburse its employees for a contribution of any amount made to the Mayor or to the Mayor's political fundraising committee; or (c) bundle or solicit others to bundle contributions to the Mayor or to his political fundraising committee. 12 LEASE NO. 19007 Landlord agrees that the Identified Parties must not engage in any conduct whatsoever designed to intentionally violate this provision or Mayoral Executive Order No. 2011-4 or to entice, direct or solicit others to intentionally violate this provision or Mayoral Executive Order No. 2011-4. Notwithstanding anything to the contrary contained herein, Landlord agrees that a violation of, non-compliance with, misrepresentation with respect to, or breach of any covenant or warranty under this Lease or violation of Mayoral Executive Order No. 2011-4 constitutes a breach and default under this Lease, and under any Other Contract for which no opportunity to cure will be granted, unless the City, in its sole discretion, elects to grant such an opportunity to cure. Such breach and default entitles the City to all remedies (including, without limitation, termination for default) under this Lease, and under any Other Contract, at law and in equity. This provision amends any Other Contract and supersedes any inconsistent provision contained therein. If Landlord intentionally violates this provision or Mayoral Executive Order No. 2011-4 prior to the Closing, the City may elect to decline to close the transaction contemplated by this Lease. For purposes of this provision: "Bundle" means to collect contributions from more than one source, which contributions are then delivered by one person to the Mayor or to his political fundraising committee. "Other Contract" means any other agreement with the City to which Landlord is a party that is (i) formed under the authority of Chapter 2-92 of the Municipal Code of Chicago; (ii) entered into for the purchase or lease of real or personal property; or (iii) for materials, supplies, equipment or services which are approved or authorized by the City Council. "Contribution" means a "political contribution" as defined in Chapter 2-156 of the Municipal Code of Chicago, as amended. Individuals are "domestic partners" if they satisfy the following criteria: they are each other's sole domestic partner, responsible for each other's common welfare; and neither party is married; and the partners are not related by blood closer than would bar marriage in the State of Illinois; and each partner is at least 18 years of age, and the partners are the same sex, and the partners reside at the same residence; and two of the following four conditions exist for the partners: (1) The partners have been residing together for at least 12 months. 13 LEASE NO. 19007 The partners have common or joint ownership of a residence. The partners have at least two of the following arrangements: joint ownership of a motor vehicle; joint credit account; a joint checking account; a lease for a residence identifying both domestic partners as tenants. Each partner identifies the other partner as a primary beneficiary in a will. (e) "Political fundraising committee" means a "political fundraising committee" as defined in Chapter 2-156 of the Municipal Code of Chicago, as amended. Waste Ordinance Provisions. In accordance with Section 11-4-1600(e) of the Municipal Code of Chicago, Landlord warrants and represents that it, and to the best of its knowledge, its Contractors and its subcontractors regarding the subject matter of this Lease ("Subcontractors"), have not violated and are not in violation of any provisions of Section 7-28 or Section 11-4 of the Municipal Code (the "Waste Sections"). During the period while this Lease is executory, Landlord's, any general Contractor's or any Subcontractor's violation of the Waste Sections, whether or not relating to the performance of this Lease, constitutes a breach of and an event of default under this Lease, for which the opportunity to cure, if curable, will be granted only at the sole designation of the Commissioner of the Department of Fleet and Facility Management. Such breach and default entitles the City to all remedies under this Lease, at law or in equity. This section does not limit Landlord's, its general Contractors' and its Subcontractors' duty to comply with all applicable federal, state, county and municipal laws, statutes, ordinances and executive orders, in effect now or later, and whether or not they appear in this Lease. Non-compliance with these terms and conditions may be used by the City as grounds for the termination of this Lease, and may further affect the Landlord's eligibility for future contract awards. Failure to Maintain Eligibility to do Business with City. Failure by Landlord or any controlling person (as defined in Section 1-23-010 of the Municipal Code ofChicago) thereof to maintain eligibility to do business with the City of Chicago as required by Section 1-23-030 of the Municipal Code ofChicago shall be grounds for termination of this Lease and the transactions contemplated thereby. Landlord shall at all times comply with Section 2-154-020 of the Municipal Code of Chicago. Cooperation with Office of Inspector General and Legislative Inspector General. It is the duty of Landlord and any bidder, proposer, contractor, subcontractor, and every applicant for certification of eligibility for a City contract or program, and all officers, directors, agents, partners, and employees of any such grantee, subgrantee, bidder, proposer, contractor, subcontractor or such applicant to cooperate with the Legislative Inspector General in any investigation or hearing undertaken pursuant to Chapter 2-55 of the Municipal Code, and to cooperate with the Inspector General in any investigation or hearing undertaken pursuant to Chapter 2-56 ofthe Municipal Code. Landlord represents and warrants that it understands and will abide by all provisions of Chapter 2-55 and Chapter 2-56 of the Municipal Code and that 14 LEASE NO. 19007 Landlord will inform its Contractors and Subcontractors of this provision and include a provision requiring their compliance with such Chapters 2-55 and 2-56 in any written agreement between Landlord and its Contractors and Subcontractors. 14.7 2014 Hiring Plan Prohibitions. (i) The City is subject to the June 16, 2014 "City of Chicago Hiring Plan", as amended (the "2014 City Hiring Plan") entered in Shakman v. Democratic Organization of Cook County, Case No 69 C 2145 (United States District Court for the Northern District of Illinois). Among other things, the 2014 City Hiring Plan prohibits the City from hiring persons as governmental employees in non-exempt positions on the basis of political reasons or factors. Landlord is aware that City policy prohibits City employees from directing any individual to apply for a position with Landlord, either as an employee or as a subcontractor, and from directing Landlord to hire any individual as an employee or as a subcontractor. Accordingly, Landlord must follow its own hiring and contracting procedures, without being influenced by City or City employees. Any and all personnel provided by Landlord under this Lease are employees or subcontractors of Landlord, not employees ofthe City. This Lease is not intended to and does not constitute, create, give rise to, or otherwise recognize an employer-employee relationship of any kind between the City and any personnel provided by Landlord. Landlord will not condition, base, or knowingly prejudice or affect any term or aspect of the employment of any personnel provided under this Lease, or offer employment to any individual to provide services under this Lease, based upon or because of any political reason or factor, including, without limitation, any individual's political affiliation, membership in a political organization or party, political support or activity, political financial contributions, promises of such political support, activity or financial contributions, or such individual's political sponsorship or recommendation. For purposes of this Lease, a political organization or party is an identifiable group or entity that has as its primary purpose the support of or opposition to candidates for elected public office. Individual political activities are the activities of individual persons in support of or in opposition to political organizations or parties or candidates for elected public office. , (iv) In the event of any communication to Landlord by a City employee or City official in violation of paragraph (ii) above, or advocating a violation of paragraph (iii) above, Landlord will, as soon as is reasonably practicable, report such communication to the Hiring Oversight Section of the City's Office of the Inspector General ("OIG Hiring Oversight"), and also to the head of the relevant City department utilizing services provided under this Lease. Landlord will also cooperate with any inquiries by OIG Hiring Oversight. [SIGNATURES APPEAR ON THE FOLLOWING PAGE] 15 LEASE NO. 19007 IN WITNESS WHEREOF, the parties have executed this Lease as of the day and year first written above. LANDLORD: IRVING STERLING VENTURE LLC, an Illinois limited liability company By: MF Properties LLC, an Illinois limited liability company, its Manager By: Franklin L. Friedman, Manager of MF Properties LLC CHICAGO TITLE LAND TRUST COMPANY not personally but solely as Trustee under a Trust Agreement dated March 28, 2005 and known as Trust Number 132968 By: Title: 16 LEASE NO. 19007 TENANT: CITY OF CHICAGO, an Illinois Municipal Corporation and Home Rule Unit of Government BY: THE DEPARTMENT OF FLEET AND FACILITY MANAGEMENT By: Commissioner APPROVED: THE CHICAGO PUBLIC LIBRARY By: Commissioner APPROVED: THE CHICAGO PUBLIC LIBRARY BOARD OF DIRECTORS By: President APPROVED AS TO FORM AND LEGALITY: BY: THE DEPARTMENT OF LAW By: Deputy Corporation Counsel, Real Estate Division 17 LEASE NO. 19007 EXHIBIT A The Premises Library Premises V •••• <: ."¦¦¦¦ ¦¦ParS Hd 18 LEASE NO. 19007 EXHIBIT B Build Out Plans [to be attached] 19 LEASE NO. 19007 EXHIBIT C Build Out Costs [to be attached] 20 3542-3552 W. Irving Park Rd. Chicago Public Library Lease No. 19007 This Ordinance shall be effective from and after the date of its CITY OFCHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT SECTION I - GENERAL INFORMATION Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: /^-^ns-Q --A^iJLiVU^ri ^;^c-o5~ / Check ONE ofthe following three boxes: Indicate whether the Disclosing Party submitting this EDS is: t N the Applicant Ovtwu-*£ 3snz W. t^.'-j f-r-k Ch. a^XU OR [] a legal enlity holding a direct or indirect interest in the Applicant. Slate 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 TI.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: if)' South LaSalle St-rppi-,, Snii-p #?75Q Chicago, IL 60603 Telephone: 773-37/-/73 <\ Fax: 77? "3 7/'3/75 Email: ___„_^eT Name of contact person: Fs-*\tJr<- Pr\ A
E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include^project number and location of property, if applicable):
L-^JLt—vx^-jt =—= y -
G. Which City agency or department is requesting this EDS?b^tlf
Jf 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
I ¦ Indicate the nature of the Disclosing Party:
j £erson [ ] Limited liability company
j Publicly registered business corporation [] Limited liability partnership
J Privately held business corporation [] Joint venture
] Sole proprietorship [ j Not-for-profit corporation
J General partnership (Is the not-for-proftt corporation also a 501(c)(3))?
] Limited partnership [ j 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 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 enlity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name ( ^ + ^ Title
Name , r Title ,
CW^t;^ UUW C-m^y T^iU
2. Please provide the following information concerning each person or entity having a direct ot 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
irt-t|-fttit"---'iTirii'','"'°~-!!gc'---"1 ™ ¦•'1 ¦" *-v "*' " --'
interest of a member or manager in a limited liability company, or interest of a beneficiary' of a^™st' estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154- )i Municipal Code of Chicago ("Municipal Code"), the City may require any such additional mlormanon from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address . . Percentage Interest in the
, , Zlio) w. M«*~>Disclosing Party , / ,^ -f
™ W l.l-,7rrUXl4;U/^Y7
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 ^jno See AirAa&b £vM/r4.
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 ofthe relationship, and the total amount ofthe 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:
lo be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
l>i 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.musl remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes }tfNo [ ] 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 [ ] 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
uaammmmi
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 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;
d.
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.
3. The certifications in subparts 3, 4 and 5 concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
• any/'Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing 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 Enlity means a person or enlity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
• any responsible official ofthe Disclosing 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 A ffiliatcd 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 ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement 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 nol been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting wilh 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.
5. 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.
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:
$L
Page 6 of 13
If ihe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, ofthe City ofChicago (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-monlh 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" 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 $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient
^
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
I. The Disclosing Party certifies that the Disclosing Party (check one)
*£$is [J is not
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 arc 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 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."
Jf 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
Tf the letters "NA," the word "None," or no response appears on the lines above, it will be j conclusively presumed that the Disclosing Parly certified to the above statements. j
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 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 enlily in the Matter? .
[ ] Yes ft No T« ¦^¦^d btwiid^ <{ 1i^,D,\J*j!y fo^ty
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 ofthe City (collectively, "City Property Sale"). Compensation for property laken 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? !
[ J Yes HN° i
i
3. If you checked "Yes" to Item D.l., provide the names and business addresses ofthe City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4 The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If the Diselosing Party cheeks 2 J^^/^^ disclose below or in an attachment to this EDS al. information required by paragraph 2. Fanure
Page 8 of 13
,nV rontract entered into with the City in comply with these disclosure requirements may make any contract
connection with the Matter voidable by the City.
X
, * i„„:„„ p,riv has searched any and all records of
1 The Disclosing Party verifies that the Disclosing Party nas s>w"<» * j
1. ine uisciosingrthe Disclosing Party and any and all predecessor entities regarding rccu. a f from slavery or slaveholder insurance policies during the slavery era (including insurance po icies 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 ofinvestments 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, il 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 nol 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 ot 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
MMHI
¦» nl>nicrW-oP"'vu,ii'o,i, -f j,(^.r-.:r:r-«inrotthP. end of each calendar quarter in
i ne uisciosiug F^iLy will submit an updatea ceiiiiiCaiion ^. formation set
which there occurs any event thai materially affects the accuracy ofthe statements and m or forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described m section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) il 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 Parly 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 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?
[ 3 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 ofthe 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
¦SHaOSHHEaUSKSMStt
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, wneiner procurement, City assistance, or other City action, and are material inducements to the City s execu licm 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 nol rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining lo 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.
Il 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 lo 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, ihe Disclosing Parly must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
nntracl being handled by the City's Department of Procurement Services, the Disclosing Party must ri*to this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Z J1 23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
T Z> the information provided herein regarding eligibility must be kept current for a longer period, frequired by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Parly represents and warrants that:
Page II of 13
of any tax administered by the Illinois
F.i. The Disclosing Party is not delinquent in the paymen' £ntjties deiinquent in paying any
Department of Revenue, nor are the Disclosing Parly or us ^ ^ ^ chargeS)
fine, fee, tax or other charge owed to the City. This tncludes, ™* sewer charges, license fees, parking tickets, property taxes or
and its Affiliated Entities will not F.2 If the Disclosing Party is the Applicant, the Disclosing Parly an ^ ^ ^ ^ Excluded use, nor permit their subcontractors to use. any facility listed by t e . • • : Parties List System ("EPLS") maintained by the U. S. General Servtces Administrali
F.3 If the Diselosing Party is the Applicant, the Disclosing equal in
contractors/subcontractors hired or to be hired in connection with the Mai c ,OT,sent ofthe
form and substance to those in F.L and F.2. above and will not, without the prior wntconsent City, use any such contractor/subcontractor that does not provide such certifications or Disclosing Party has reason to believe has not provided or cannot prov.de truthlul certuicauo .
NOTE: If the Disclosing Party cannot certify as to any of ihe items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.
: (1) warrants that he/she is authorized to execute ofthe Disclosing Party, and (2) warrants that all and Appendix A (if applicable) arc true, accurate
Jut«\ tf ortVv "SSpcz tT~ and not persona^
Tte instrument is executed by the undersigned Land f rusta*, Mt personally but sotetv as Trustee in the exercisa ot the powr and authority contertad upon and vested in it as such Trust*, tt is eipressly understood and agreed that all the warranties. Mamnities. representations, covenants, undertakings aoi agreements heiein made on the part ol the Trustee an undertaken by it solely in its capacity as Trustee and mt personalty. No persona) liability or personal responsibility tj assumed hy or shaU at any time be asserted or entorcaaMt •gainst the Trustee on account of any warranty, indemnity, rtpteseutalion, covenant, undertaking or agreement of m Trust** in this instrument.
l to before me on (date) _^A^\^A-V
Signed and sworn «, ^ --_ - - ¦ v .
at Cl^>OL^— County' -i^-4^ (
Notary Public.
The foregoing statementa are made on the information and belief and not made, as statements of fact.*
"OFFICIAL SEAL" SUSAN GH6LERTER
,0 , : NotaryPut*c.a«t«^t«no*« ?
Page 12 of 13 ? Comrrt^E^^^^MM
ECONOM,C DISCL™SAMENT ANO 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 Jegal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent It is not to be completed by any legal en ity 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 lo the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers ofthe Disclosing Party listed in Section ILB. 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 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 ofthe 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?
[ ]Ycs ^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 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 AFFIDAVII
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 ownei-ship interest in the Applicant.
1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe MunicipaJ Code?
>3No
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 ofthe Municipal Code?
[ JYes ^No [ ] 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 ofthe 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 OFTHE ASSOCIATED EDS.
EXHIBIT A
The Disclosing Party is the Landlord under a Lease with the City ofChicago as» Tenant for the Independence Branch ofthe Chicago Public Library at ^48 West Irving Park Road, Chicago, Illinois.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 - GENERAL INFORMATION
A , Legal name of the Disclosing Party submitting this EDS. Include d/b/a/if applicable:
%r*n SfcrU Vej^re. IX-C^l/i^ tii-ty u*f*y.
Check ONE of the following three boxes:
Indicate whether the.Disclosing Party submitting this EDS is:
]^'thc Applicant
OR
[ ] a legal entity holding a direct or indirect interest in the Applicant. Stale the legal name of (he
Applicant in which ihe Disclosing Parly holds an interest: ^
OR
3. {] a legal entity with, a right of control (sec Section II.B.l.) State the legal name ofthe entity in
which the Disclosing Parry holds a right of control:
B. Business address of the D isclosing Parly:
QJ0 \ U Mtat^ Aye-
Telephone: IK?! Wh\Fax: m^\'9XR En»/. H K^i
Name of contact person:
E. Federal Employer Identification No. (if you have one):
F, Brief description of contract, transaction or other undertaking (referred to below as the "Mailer") to whichlhis EDS pertains. (Include project number and location of property,.if applicable):
G. Which City agency or department is requesting fais.iZDi,^
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following;
Specification # ¦ and Contract #
Pase 1 of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A, NATURE OF THE DISCLOSING PARTY
I. Indicate the nature of the Disclosing Party:
[] Person ^^Limited liability company
[ J Publicly registered business corporation [ ] Limilcd liability partnership
[] Privately held business corporation [] Joint venture
[ ] Sole proprietorship ¦ [,] Not-for-profit corporation
[ ] General partnership; . (ls lhe not-for-profit corporation also a 503(c)(3))?
[ ] Limited partnership [JYes [ ] 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 Slate of Illinois: Has.Ihe organization registered lo do business in lhc State of Illinois as a foreign entity?
[ ] Yes [ }Np [ ] N/A
13. IF 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-profii corporations, also list below all members, if any, which arc legal entities. If there are no such members, write "no members." For trusts, eslalcs or other similar entities, list below the legal litleholder(s).
If .the entity is a general .partnership, liinited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner^ managing riiember, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed.below niustsubmil an EDS on its own behalf.
Name Jj. . , Title , / . , Jyi „
/vif r^^/:/^--^u^.:rthtr(i^ fU.jf ^ff rh^r-
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 partnershipibr joint venture,
/&\ Page 2 of 33
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 an}'applicant which is reasonably intended fo achieve full disclosure.
Name " Business Address .¦>.>• a Percentage Interest in the
AVHk-v C frfvW *>* W T( ^ .2 ?SECTION III- BUSINESS RELATIONSHIPS WITH CITY ELEC1 F1CIALS
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?.
No See ^vvuFff A
If yes. please identify below tliename(s) of such.City elected official(s) anddescribe such relationship^): -,
SECTION IV DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name andbusincss 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 arc paid solely through the Diselosing Party's Tegular 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 retained or anticipated Address to be retained) .
Relationship to Disclosing Party Fees (indicate whether
(subcontractor; attorney, paid or estimated.) NOTE:
lobbyist, etc.) "hourly rale" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
J)^Check here if the Disclosing Parly has not retained, nor expects to retain, any such persons or entities.
SECTION Y - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract wilh the City-must remain in compliance with their child support obligations throughout the contract's term,
lias any person who directly or indirectly owns 10% or more,of the Disclosing Parly been declared in arrearage on any.child support obligations by any Illinois court of.competent jurisdiction?
No [ ] No.pcrson 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 wilh that agreement?
[] Yes f ]No
B. FURTHER CERTIFICATIONS.
, 1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article I")'(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Parly submitting this EDS-is the Applicant and is doing business with the City, then the Disclosing Parly certifies as follows:.{i)-neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or'placcd 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; ami (ii) the .Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: If Article 1 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 3 3
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities dentificd in Section ll.B; I. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible oi" voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the dale 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, slate or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft;, forgery; bribery; falsification or destruction of records; making false
- statements; or receiving stolen property;
c: are not presently indicted for, or.criminally or civillycharged by, a governmental entity (federal, stale or local) with committing any of the offenses set forth in clause 13.2.b. of this Section Y;
have not. within a five-year period preceding lhc dale of this EDS, had one or more public transactions (federal, stale 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 Gity 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 Part)';
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 Parlies");
.• any "Affiliated Entity" (meaning a person or entity that, direclly^or ihdireclly:,controls.the Diselosing Parly, is controlled by the Disclosing Parly, or is, wilh 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 lo do business with-federal or slate 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 Conlraclor, is controlled by it, .of, with the Contractor, is under common control of another person or entity;,
• any responsible official of the Disclosing Party, any Conlraclor or any Affiliated Enlily or any
- other official, agent of employee of the Disclosing Parly, any Conlraclor or any Affiliated Enlity, . acting pursuant to the direction or authorization of a responsible official of lhc 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 befofe the date ofsuch 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 atlempting. to bribe, a public officer or cniployee of the City, the Slate ofIllinois; 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 employcc's official capacity;
agreed or colluded wilh 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 anadmission 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 Stales of Amerjca that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Parly nor any Affiliated Enlity 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: theSpecially Designated Nationals List, the Denied Persons List, the Unverified.List, the Enlity 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 Parly is.unable lo 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").
9. To the best ofthe Disclosing/Party-S knowledge, after reasonable inquiry, the following is a complete list/of all gifts that the Disclosing "Parly has given or caused to be given, at any time during the 12-montli 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 nol 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 wilh "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)
f 3 is |^.s not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code. .
If the Disclosing Party IS a financial.insuiulion, then ihe 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 ofthem 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 lhc 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 2-3 2-4 5 5(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 "N A," the word "Nonei" or no response appears on the lines above, it will be conclusively presumed that lhc Disclosing Party certified to;the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any Words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D,
1. In accordance with Section 2-15.6-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or W;own name or in the name of any other person or
entity in the Matter? •• , , ^ k i , p- j>
[ J Yes J^Nol* ty* Wl J^led^ :\U U^-.b'-^ U\Hr
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.
2; 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 n^me of any other person or enlity in the purchase of any properly 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 Property Sale?
IJ Yes XNo ;
, 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 Parly further certifies that ho prohibited financial interest in the Mailer will be acquired by any City official or employee.
E. CERTIFICATION REGARDING .SLAVERY ERA BUSINESS
picasecheck cither 1. or 2. below. If the Disclosing Party checks 2,, the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph.2. Failure to
Page 8 of 13
.comply with these disclosure requirements may-make any contract entered into with the City in :connection with the Matter voidable by the City.
1 The Disclosing Party verifies that thc Disclosing Party has searched any and all records of the Disclosing Parly 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 of 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 DisclosingRarly verifies that the following constitutes full disclosure of all such records, including lhc names of any and all slaves or slaveholders described jn 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 lo Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City arc not federal funding. ,
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995;who have made lobbying contacts on behalf of the Disclosing Party wilh respect to the M atter: (Add sheets if necessary):
(if no explanation appears or begins on ihe lines above, of if lhc letters "NA" or if the word "None" appear, it wilfbe conclusively presumed that Ihe Disclosing Party means fhal NO persons or cnlities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Parly with respect to the Mailer.)
2. The Disclosing Parly has not spent and will nol expend any federally appropriated funds to pay any person or enlity listed in Paragraph A.l. above for his or her lobbying activities or lo pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member 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 coopcralive.agrecment, 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 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 :Rcvcnue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
.'. 5. If the Disclosing Party is fhcApplicant, the Disclosing Party must obtain certifications equal in . form and substance to paragraphs A.l. through A.4. above from all stibcontractbrs before it.awards any subcontract and the Disclosing Party must maintain all such subcontractors' certification's 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 M atter is federally funded, federal regulations require the, Applicant and all proposed subcontractors to submit the following information with their .bids: or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
,] Yes [ ] No
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative.action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.) . .
f J Yes [ ] No
Have you filed with the "Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment.Opportunily 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 cl&use?
1 ] 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 wilh the Matter, whether procurement,- Cily 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 Mailer. The Disclosing Party understands that iimust comply with all statutes, ordinances, and rcgulations 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 ordinanccs.and a training program is available online at www.ci tvofchicaffo.org/Elhics , and may also be obtained from thc-City's Board of Ethics, 740 N,
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party musl 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 olher agreement in connection with which il 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), a} law, or in equity, including terminaling the Disclosing Parly's participation in. the Matter and/or declining to allow the Disclosing Party to participate in other'transactions with the City. Remedies af law for-a false statement of material.fact may include incarceration and an award to the City of treble damages.
ll 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 Ibis EDS. ,
' E. The.information provided in (his.EDS must be kept current. In the event of changes, the Disclosing Party must 'supplement this EDS up lb the time the City takes action on the Matter. If the M alter is a :. contract-being handled by the City's Department of Procurement Services,-the Disclosing Party must updale.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 arid warrants that:
Page 11 of 13
F.I. The Disclosing Party is not delinquent iii the payment of any tax administered by the Illinois Department of Revenue, nor arc the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed lo ihe City. This includes, but is not limilcd 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 Party will obtain from any contractors/subcontractors hired or 1o be hired in connection with the Mailer certifications equal in form and substance to those in F. 1. and F.2. above and will not, without the prior written consent of (he City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Parly cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
\ 3 J
Under penally of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and slalements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of lhc date furnished to,the City. . i i i |'3.,
* 1 A
/
~~7 Tt j :——
(Print or type n;fme of Disclosing Party)
By:
(Sign here)
(Print or lype name of person signing) rC AA F !>
(Print or type title of person signing)
at
Signed and sworn to before me on (date)wc^\ V
C~o c k. County, VVo \_i (slate).
Notary Public.
Commission expires:
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 f o be completed by any legal entity which has only an indirect ownership interest in the Applicant.
¦Under Municipal Code Section 2^154-01 5, tile Disclosing Party-must disclose:whelher 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 dale 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 airy of the folloAving, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mbther-inrlaw, son-in-law, daughter-in-law, stepfather or;stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (3) all executive officers of the Disclosing Parly listed in Section IJ.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Parly 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 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 Parly or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" wilh an elected city .official or department head?
.[ ] Yes jX(No
If yes, please identify below (1) the name and title of such;pcrson, (2) Ihe name of the legal entity to which such person is connected; (3) the name and title of the elected eity official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
PageT3of 13
CITY OK CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLA W/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only-by (a) the Applicant, and (b) any legal entity which has aI'direct'.ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). K 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 2rl 54-010,.is the Applicant or any O wner identified as a building code scofflaw or-problem-landlord pursuant to Section 2-92-416 of the Municipal
.Code?-.;
[ ] Yes JxJno .
2, If the Applicant is a legal entity publicly traded on any cxchange.is any officer or director of
the Applicankidentificd as a building code scofflaw or problem landlord pursuant to Section
2-92-416 of the Municipal Code?
[ ] Yes [ ] No ^
3. Ifyes to (1). 6r: (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 the building or
buildings to which the pertinentcode violationsapply.
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.
&
EXHJBJIA
Disclosing Party is the Landlord under a Lease with the Gity of Chicago as Tenant for the Independence Branch ofthe Chicago Public Library at 3S48 West Irving Park Road, Chicago, Illinois.
.An entity with common pwners as the Disclosing Parly has submitted an application, fo vacate an alley located near the corner of Peterson and Albany Avenues In Chicago, Illinois.
CJTY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 - GENERAL INFORMATION
Legal name of (he Disclosing Party submitting-this EDS. Include d/b/a/if applicable:
Mr7 frcp&M. LU, ft-s;flU<- ly-fei U4 c^fy
Check ONE of the following three boxes:
Indicate whether thc Disclosing'Party submitling rhisEDS is;
,1 3 tne Applicant ^
OR
[] s legal enlity holding a director'indirect interest in the Applicant. Slate the legal name ofthe
Applicant in which uVc- Disclosing Parly holds an interest: " '
OR ~ "'"
3. a legal entity with a fight of control (sec Section II.B.l.) Slate, the leiyil name of the entity in
which the Disclosing Parly holds a right of control: X.^lpa S^Ql^ Xf liWf
Business, address of the Disclosing Party; ^ \J() / (a/< ¦infers
ti,.,^
Telcphone:;??^^
Name of contact person:
Federal Employer'Identification No. (if you have one): u ' [
F. Brief description of contract, transaction or olher undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project mimbcr and location of property, if applicable):
G. .Which City agency or department is requesting this EDS?£^^.o^ Q
If the Matter is a contract being liandled by lhc City's Department of Procurement Services, please complete the following:
Specification # . and Contract ii
Page 1 of 13
SECTION II DISCLOSURE-OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1 . Indicate the nature of thc.Disciosing Party: I Person *>
[ j Person Limited liability company
[ ] Publicly registered business corporation [ J Limited liability partnership
[ ] Privately held business corporation [ ] Joint venture
[ ] Sole proprietorship [ ] Not-for-profit corporation
[ J General.partnership (Is the not-for-profit corporation also a 501(c)(3))?
[] Limited partnership [JYes 13 No
[ 3 Trust | 3 Olher (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: Hasthe organization registered to do business in the State of Illinois as a foreign entity?'
[3; Yes { ) No [. J 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 enlity; NOTE: For not-for-profit corporations, also list below all members, if any, which arc legal entities. If there are no such members,-write "no members." For trusts, estates or other similar entities, list below the legal lillcholder(s).
If the entity js ,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 enlily that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
i i IT ' 1 Title
2. Please provide the following ihfonnaljon 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
iniercsl of a member of manager in a limited liability company, or interest of a beneficiary of a tin si, estate or other similar entity. If none, stale "None." NOTE: Pursuant lo 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 lo achieve full disclosure.
Maine Business Address - Percentage Interest in the
SECTION. HI - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapler 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
If yes, please identify below the name(s) of such City elected official(s) and describe such relalionship(s):
SECTION IV - DISCLOSURE OF SUBCONTR ACTORS 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 lhc Matter, as well as the nature ofthe relationship, and the total amount of ihe fees paid or estimated to be paid. The Disclosing Parly 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.-profil 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 lo influence any legislative or administrative action.
If lhc Disclosing Party is uncertain whether a disclosure is rcquiredunder this Section, the Disclosing Party must cither ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business retained or anticipated Address to be retained)
Relationship lo Disclosing Party Fees (indicate whether
(subcontractor, attorney, paid or estimated.) NOTE:
lobbyist, etc.) "hourly rate" or "t.b.d." is
nol an acceptable response.
(Add sheets, if necessary)
j^CIieck here if ihe Disclosing Party-has.n'ol 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.
Muk any person who directly or indirectly owns 1.0% or more of the Disclosing Partybeen declared in arrearage' on any child support obligations by any Illinois court of competent jurisdiction?
"^^N o , | ] No person directly or indirectly owns 10% or more of lhc
Disclosing Parly.
If "Yer.," has the person entered into a court-approved agreemcnl for payment of all support owed and is the person in compliance with that agreement?
[JYes (]No
Bv FURTHER CERTIFICATIONS
I Pursuant to Municipal Code Chapter 1-23. Article 1 ("Article I")(whic-h the Applicant should -consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing,Party submitting this EDS is lhe;Applicant and is doing business wilh the City, then the Disclosing Party certifies as follows: (i) neither the'Applicant nor any controlling person-is currently indicted .or charged wilh.or lias' admillcd guilt of, or has ever been convicted of, or placed under supervision for, any crtmjiirjj offense involving nctual, attempted, or conspiracy to. commit bribery, theft, fraud, forgery, perjury, dishonesty or.deceit against an officer or employee of lhc City or any sister agency; and (ii) the Applicant understands and acknowledges lhat compliance wilh Article;! is a continuing requirement for doing business with Ihe City. NOTE: If Article I applies to the Applicant, the permanent compliance nun-flume in. Article I supersedes some five-year compliance '.timeframes in certifications 2 arid 3 below.
Page 4-of 13
2. The .Disclosing Parly and, if the Disclosing Party is a legal entity, fill of those persons or entities identified in Section II.B.l. of this EDS:
v ucc not presently debarred, suspended, proposed for debarment, declared ineligible,or voluntarily excluded from any transactions by any federal, stale or local unit of government;
b. have not, within a five-year'period, preceding the dale 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 of,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;'
. •:. arc not presently indicted for, or cri niinally or civi Hy charged by, a governmental - entity (fed eral, :.(alc- or local) with committing any of the offenses set forth in clause B.lb., of this Section V;
d. have hot, 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
o. 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, instituled.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 Party;
" any "Coiitt actor" (meaning any .contractor or .-subcontractor used by the Disclosing Party in connection, with the Matter, including but not limited lo all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Panics");
- any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disc losing Party, is controlled by the Disclosing Parly, or is, with the Disclosing Party, under coni'morV control of another person or entity, indicia of control include, without limitation: interlocking nianagcme.nl or ownership; identity of interests.among family members, shared facilities a.iid equipment; common use of employees; of organization of a business .enlity. following-the ineligibility of a.business entity to do business with federal or slate or localgoverrimcht, including iiie Cit\\ using'substantially the same management, ownership, or principals as the ineligible entity): \viih respect to Contractors, the term Affiliated Entity means a person or entity thai directly or indirectly controls lhc Conlraclor, is controlled by il, or, with lhc 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 oilier official, agent or employee of lhc Disclosing Party, any Contractor of any Affiliated Emily,
.-u /iiig -puvsuanl to the direction .or authorization of a responsible official of the Disc-losing Party, any 'Contractor or-any Affiliated Entity (collectively "Agents'").
Neither the Diselosing Parly, nor any Contractor, nor any Affiliated Entity of either the'Disclosing Parly orfcny Contractor nor any Agents have, during the five years before the dale this EDS is signed, or, wilh respect to a Contractor, an Affiliated Enlity, or an A ffilialcd Entity of a Contractor during the five years before Ihe-dale of such Contractor's or Affiliated .-Entity's contract or engagement in connection with the Matter:
a bribed or attempted to bribe, or been con victed, or adjudged guilty of briber)' or attempting to bribe, ;v publ ic officer or employee of ihe City. thc.Statc of Illinois, or any agency of lhc federal .government or of any state or local government in the United Slates of America.-in thai officer's or employee's official capacity;
h. agreed or colluded with other bidders or prospective bidders, or been a parly toairy such
agreement, -or been convicted or adjudged guilty of agreement or collusion amo.n'g bidders or prospective bidders, in restraint of freedom,of competition by agreement to bid a fixed price or otherwise: or
.<¦ ina.de an admission of such conduct described in a. or b.above that is a matter of record, but have nol been prosecuted for such conduct; or
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Parly, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from -contracting-with .any unil of stale or local government as a result of engaging iii or being convicted of (1) bid-rigging iu.violation of 720 ILCS 5/33E-3; (2) bid-rotating in violaiion of 720 ILCS 5/33E-4; or (3) any similar offense of any slate or of the United Slates, of America thai containsthe same .elements as the offense of bid-rigging or bid-rotating.
-.'>'. Neither the Disclosing Party nor any Affiliated Enlily is listed on any of the following lists . mamlainad by the Office of Foreign Assels Control, of the U.S.,Department ofthe Treasury or die JTurcait 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 Enlily List and the Debarred L.isl.
6. The Disclosing Party undcrslands 'and shall comply with the applicable requirehienls of Chapters 2o5 {Legislative Inspector General), 2-56 (Inspector General) 'and 2-156" (Governmental Ethics) ofthe Municipal Code. .
If ihe Disclosing Party is unable lo certify lo any of the above statements in. this Part B (Further Certifications), the Disclosing Party must explain below: / 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 nil current employees of the Disclosing Party who were, at any time during the 12-inonlh period preceding.the execution date of this EDS, an employee, prelected or appointed official, of the City "of Chicago (if none, indicate with "N/A" or "none"), fjl fL
9. To (he best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that (he Disclosing Parly has given or caused to be given, at any time during the 12-inonlh period preceding the execution dale 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):anything made generally available to City employees or to the general public, or (ii) food or drink provided in Ihe course of official City business and having a retail value of less than &2(f per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
C. • CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION.
1. The Disclosing Party certifies that the Disclosing Party (check one)
f] is ^is not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
2;. If the Disclosing Parly IS a financial institution, then the Disclosing Party pledges:
"We'are notand will nolbecomc 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 iender 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 of the Municipal Code, explain here (utla.ch additional pages if ncccssary):^y^
Page 7 of 13
If flic letters "NA," llic word "None," or no response appears on tb'e lines above, it will-be conclusively presumed thai 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.
I . In accordance with Section 2-156-110 of the Municipal Code: Docs 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? I > r .-y ( , t>
[jyes j^No Tc tUWT Jtivswl*-^ «* Tl)t WscAo^w/A'
NOTE: If you checked "Yes" to Item D.J., proceed to Items D.2. and D.3. If you checked "No" to Item D.l ...proceed to Pari E.
"Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shatl 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 lhat (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 Properly Sale"). Compensation for property .taken pursuant lo the City's eminent domain power docs nol. constitute a financial interest within lhc meaning of this Pari D.
Does lhc Matter involve a City Property Sale? []Yc.s []"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 lhat no prohibited financial interest iu the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither 1. or 2. below. If the D isclosing 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 juakc any contract entered into with the Cily in connection with (lie Matter'voidable by the City.'
V l. The Disclosing Parly verifies that the Disclosing Party has searched any and all recdfds
•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 Ihe following constitutes full disclosure of all such-records, including the names of any arid 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
¦fuitdadi. proceed to Section VII. For purposes of this Section VI, lax. credits allocated by-the'City and proceeds of debt obligations of the Cily arc not federal funding.
A. CERTIFICATION REGARDING LOBBYING
l. List below the names of all persons or entities registered under the- federal Lobbying 'DiselosHt'e Aci of 1995 who have made lobbying contacts on behalf ofthe Disclosing Party with respcoi to -the Matter: (Add sheets, if necessary):
• Of «o explanation .appears or begins on the'lines above, or if the letters "NA" or if the word "None" appear ii 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 ou behalf of the Disclosing Party with respect to the Matter.)
i The Disclosing Party has noLspcnl and will not expend any federally appropriated funds to pay
f.uy. pcisd!) 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
Te.de.raHy funded grant or loan,.entering into any cooperative agreement, or to extend, continue, renew,
amend; of modify any federally funded contract, grant, loan, or cooperative agreement.
<4, Page 9 of 13
The Disclosing Parly will submit an updated certification at the end of'each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A.l. and A.2. above.
4. The Disclosing Party certifies that cither; (i) it isnoi aivorganization described in section 5ij\(c){4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section . :HM (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 J. through A. 4. above from nil subcontractors before it awards.any subcontract and (lie Disclosing Party must maintain all such subcontractors' certifications for (he duration ofthe Matter and must make such certifications promptly available to.lhc Cily 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 oi'in writings at the.outset of negotiations.
is the Disclosing Parly the Applicant?
! ] Yes [ ] No
If "Yes," answer Ihe three questions below;|109|¦., ljayc you developed and do you have on file jaffirmaliyc action programs pursuant to applicable federal regulations? (Sec 41 CFR Part 60-2.)
{] Yes [ ]No
|109|Have you filed with the Joint Reporting •¦Committee,the Director of the Ofiice of Federal Contract Compliance Programs, or the Bqual Employment -Opportunity Commission all reports due under the Applicable filing requirements?
I ] Yes [] No
.L Have you participated in any previous contracts or subcontracts subject'lo'the-equal opportunity clause? .
! I Yes I] No
li you cheeked "No" to question J . 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:
/v. The certifications, disclosures, and acknowledgments contained in Ibis EDS will become part of any ¦conn net'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 Mailer. The Disclosing Party understands thai it nntsl"comply with all statutes, ordinances, and regulations on which this EDS is based.
R The, City's Governmental Ethics and "Campaign Financing Ordinances, Chapters 2-156 and 2-164 of. . she 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 Sine at v/wwxityofchicnRO.orfi/Ethics, and may also be obtained from,the City's Board of Ethics, 740 N.
Sedgwick Mi., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
¦ C. 'if the City determines that any information provided in this EDS is false, incomplete or'inaccurate, 5*hy 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 of voiiT), at law, or in equity, including 'terminating the Disclosing Party's participation in the Matter anti/or declining lo allow the Disclosing Parly to participate in other transactions with the City, Remedies at law foi ;t false statement of material fact may include incarceration-a rid-an award to the City of treble ¦damages.
D, if is the City's policy to make (his document available to the public,on its Internet site and/or upon, request. Sonic or all ofthe information provided on this EDS and any attachments to (his EDS may be vividc available fo the public on the In'tcrnet/in response io a Freedom of Information Act request, or iVUicnvisc. Hy completing and signiiiglhis EDS, the Disclosing Party waives and releases any possible .rights or claims which it may have against the City in connection with theptiblicrclcasc of information contai ned in this EDS and also authorizes the Cily io verify the accuracy of any information submitted in ibis EDS.
'.€.' The information provided in this EDS must be kept current. In the event of changes, the Disclosing Farly-'iiuisl supplement this EDS up to the time the City takes action oh'the Matter. If the. Matter is a coiitrruM: being handled by the .City's Department of Procurement Services, the Disclosing Parly must update'.this EDS as Ihe contract requires: NOTE: With respect lo Matters subject to Article 1 of Chapter i -23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), lhc 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 Parly represents and'warrants lhat:
Pago, 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 Parly or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limilcd to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use. any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. 1. and F.2. above and will not, without the prior written consent ofthe City, use any such contractor/subcontractor that docs not provide such certifications or lhat the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Parly cannot certify as to any ofthe 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 ofthe Disclosing Party, and (2)-warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) arc true, accurate and complete as of the date furnished to the Cily.
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(Print or type name of Disclosing Party)
(Sign here)
i!r\ \ s" \(l cs\X\l(S
(Print orlypc name of person signing) A/1
(Print or type title of person signing)
Signed and sworn to before me on (jdale) ~.J is j j/ -J , oCy i u
at (Zoo i<, County, "Xl \ (state).r
Notary Public.
Commission expircs:_
OFFICIAL SEAL CARMEN L VILLA Notary Public - State of Illinois My Commission Expires Apr 13, 2018
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVI T
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 mitres* in the Applicant exceeding 7.5 percent It is hot to be completed'by any legal entity wltsch has only ati indirect owrici shipinterest in the Applicant.
¦Diidcr Municipal Code Section 2-154-015, the Disclosing Paity must disclose whether such Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof currently has a "fVuniliiil relatiprfsliip" with jury 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.ariy 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 (1) all executive officers of lire Disclosing Party listed in Section II.B.l.a:, if the Disclosing Party isa corporation;, all 'partner's ofthe Disclosing Party, if the Disclosing Party is a general partnership; idl general partners and limited, partners of the Disclosing Party, if the Disclosing Party is a limilcd 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 o wnership 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 ciinentiy have.a "familial relationship"'with an elected cily official or department head?
[ J Yes ^No
Tf yes,-please identify below (1) the name and title of such person, (2)'thc name of tlic;legal;cnti(y lo which such person is connected; (3) the name and. title ofthe, elected city official or department bead to whom such person has is familial relationship, and (4) the precise nature'of such familial relationship.
\ Page 13 of 13
CITV OF CHICAGO ECONOMIC DISCLOSURE-STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCQFl<]LAW/PROBLEM LANDLORD CERTIFICATION
This Appendix Is to be completed only by (a) tlx; Applicant, and (b) any legal entity which has a direct oniiership interest in the Applicant exceeding 7.5 percent (an."Owner"). Ii is not to be completed by any legal entity which has only an indirect ownership'interest hi the Applicant.
j 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 j^N-o
If the Applicant isa 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?
( j Yes I J No. p(\-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 thc^peitment code violations apply.
FILLING OUT THIS APPENDIX 13 CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX BIS INCORPORATED BY -REFERENCE INTO, AND MADE A PART OF, THE ASSOCIA TED 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 ASSOCI ATED EDS.
EXHIBIT A
An enlily in which Disclosing Parly has aivinterestis the Landlord under a Lease with the Cjty of Chicago as Tenant for the Independence Branch of the Chicago Public'Library at 3548 Westirvhrg Park Road, Chicago, Illinois.
Ah entity in which Disclosing Party has an interesf has submitted an application to vacate an alley located near the corner of Peterson and Albany Avenues in Chicago, Illinois,
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 - GENERAL INFORMATION
Legal name ofthe 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. Slate the jegal name of the_»i.
Applicant in which the Disclosing Party holds an inlcrest:Xrv>'Vj ^Fgr VgyAhA"^ ov> -U/^;
OR li'*'\cX 11^,1^ ctf^fa-y
3. [] a legal entity with a right of control (see Section II.B.l.) State the legal namr/of the entity in
which the Disclosing Party holds a right of control:
Business address ofthe Disclosing Party:
Telephone: ^ 73v37f- & W ^g^/^/ ^Email^^^'^X^^
Name of contact person:
Federal Employer Identification No. (if you have one):
Brief description of contract, transaction or other undertaking (referred to below as ihe "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):
G. Which City agency or department is requesting this EDS1U(M . ~t~' ^1 \ j/
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
(A Vcr. 01-01-12
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
I. Indicate the nature of the Disclosing Party:
[ ] Person f ] Limited liability company
[ ] Publicly registered business corporation [ ] Limited liability partnership
[ ] Privately held business corporation [ 3 Joint venture
[ 3 Sole proprietorship [ J Not-for-profit corporation
[ 3 General partnership (Is the not-for-profit corporation also a 501(c)(3))?
ft£ Limited partnership [ 3 Yes [ ] No
[ 3 Trust [ 3 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 Stale of Illinois: Has ihe organization registered to do business in the Stale of Illinois as a foreign entity?
[] Yes [3 No [3 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 arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal titlcholder(s),
If the enlity is a general partnership, limited partnership, limited-liability company, limilcd liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity lhat controls Ihe day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit-an EDS on its own behalf.
r€r~
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 ofChicago ("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
. v tcV^ jj f\ \ Disclosing I ", . ( Jj
r%nV\U Lr^wWvy^fc) Vis PeTeQ^ ^/e-.tluy^l jWzVK > Meed a«/«vcfl\^
——. J . - ,—J~^^"*t)f^^^'7~ '"" J— Q — ¦¦ ¦¦¦ —————— — ¦— ¦ .-\
^^tTc F^W^oi Mas**ttiiap^ uWlj[roj owwU
' '^SECTION Jlfl^USINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapler2-156 ofthe Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[]Yes f#No 5tt ¦FJM&tt' A
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 enlity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and (he total amount ofthe 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 lo 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 underlaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
^ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantialowners 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 PQ No [ ] No person directly or indirectly owns i 0% 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 t] 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 lhc Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
arc nol 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;
arc not presently mdicted 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 live-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 Olher Retained Parties");
any "Affiliated Emily" (meaning a person or entity lhat, 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 io do business with federal or state or local govcrnment,"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 dial 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 Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any slate 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, Affilialed 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 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 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 Ihe 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 to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
fr/ft
Page 6 of 13
Jf the tellers- "NA," ihe word "Mono," or no response appears on the lines above, it will be conclusively presumed thai the Disclosing Parly 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 ofthe Disclosing Parly 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"). /\ljf
9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Parly has given or caused to be given, at any time during the 12-monlh period preceding the execution date of this EDS, lo an employee, or elected or appointed official, of the Cily ofChicago. 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 wilh "N/A" or "none"). As to any gift listed bclowy 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^isnot
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party TS a financial institution, then the Disclosing Party pledges:
"Wc are not and will nol become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a.predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss 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 Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapler 2-32 of the Municipal Code, explain here (attach additional pages if necessary):^^ ¦ ^
Page 7 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same meanings when used in ihis Part D.
in accordance with Section 2-156-110 of the Municipal Code: Docs any official or employee
ofthe City have a financial interest in his or her own name orin the name of any other person or
entity in the Matter? . . i | i f n r\{ ( , p L>
fJYcs !#NoT^>Ub^T WiMW^ dT rhe- ^dbJMrvj cxr\y
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 Cily, 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 hot constitute a financial interest within the meaning of this Part D.
Dous the Matter involve a City Property Sale?
[} Yes , 03 No
If you checked "Yes" to Item D.lprovide 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 cither 1. or 2. below. If the Disclosing Party cheeks 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 wilh the Matter voidable by the City.
X '¦ The Disclosing Party verifies that the Disclosing Parly 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 VJ. 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 inlo 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) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 19S6 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 il 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?
f ] 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? (Sec 41 CFR Part 60-2.)
[]Yes []No
Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission al! 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 I. 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 tak ing other action with respect to ihe 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.cityofclricapo.orE/Etbics . 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 Cily. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
Il is the City's policy to make this document available lo 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 thepublic 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, lu the event ofclumgcs, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Parly must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Muuicipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information piovidcd herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 8nd Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
/\ Page 11 of 13
fc
F.l. The Disclosing Parly is not delinquent in the payment 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, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, properly taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will 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 hot, wilh out 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
\(,X par fm£^s;ki^ o-j^j/^ Cie*ifrd fat
Under penalty of perjury, (he 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) arc true, accurate and complete as. of the date furnished to the City.
H-°At<"V i^Ot,'r^,S L.'f? Civ,
(f'rint or type name of Disclosing Party)
!">'Aitk.i;<\ le^'lfViAv^
By:
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(Print or type name of person signing)
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¦COP"'- i < ¦'¦¦ VS U W v
(Print or type Title of person signing)
OFFICIAL SEAL >
CARMEN L VILLA '>
LNotary Public - State ot Illinois >
My Commission Expires Apr 13. 2018 >
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is io be completed only by (a) the Applicant, and (b) any legal enlily which has a direct ownership Interest in the Applicant exceeding 7S percent. ft is uot to be completed by any legal entity which has only an Indirect ow nership interest in 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 tin's 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, sicpson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Parry" means (I) all executive officers ofthe Disclosing Party listed in Section II.B.l.a., if Ihe Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company, (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disc-losing 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?
t ] Yes p«3 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 ofthe elected city official or department head to whom such person has a familial rclatioaship, 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.S 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 2-92-41.6 of theMunicipal Code?
[ ]Yes >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 theMunicipal Code?
[ ]Yes [JNo Not Applicable
3. If yes to (1) or (2).abovc, 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 io 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.
EXHIBIT A
An entity in which Disclosing Party has an interest is the Landlord under a Lease with the Ciry of Chicago as Tenant for the Independence Branch of the Chicago Public Library at 3548 West Irving Park Road, Chicago, Illinois.
An entity with common partners as the Disclosing Party has submitted an application to vacate an alley located near the corner of Peterson and Albany Avenues in Chicago, Illinois. ^
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION 1 -- GENERAL INFORMATION
Legal name ofthe 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
Jp^a legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthe Applicant in which the Disclosing Party holds an interest:^rvi'™ f>f£f \kr^\i/f^ ^""^.l^
OR |j3fJlufH'^ c**rc>«y
3. [] a legal entity with a right of control (see Section II.B.l.) Slate the legal name of the entity in
which the Disclosing Party holds a right of control:
Business address of the Disclosing Party: ^ ^ 1 K/ > f^^O /A^ '
Telephone: Email: g"ierlu^-iOrTi^PrT^jL^^"^
Name of contact person: AitTtT P{ \^(\jt\iV(\
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):
^W^-^-ii^i^-^i^^ y-
Which City agency or department is requesting this EDS?
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
vcr. oi-oi-n Page 1 of 13
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY 1. Indicate the nature of the Disclosing Party:
[] Person []
[ ] Publicly registered business corporation [ ]
[ ] Privately held business corporation [ ]
[ ] Sole proprietorship [ ]
[ ] General partnership (Is
[ ] Limited partnership
Trust [ ]
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
the not-for-profit corporation also a 501(c)(3))?
[]Yes []No Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
3. For legal entities not organized in the Stale of Illinois: Has the organization registered lo do business in the Slate of Illinois as a foreign entity?
[]Yes []No []N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
i
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 ofthe Disclosing Party. NOTE: Each legal entity listed below must submit au EDS on its own behalf.
Name Title
_^Miir^Ay^.J^i^a^_- Itej&eE
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 ofChicago ("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
J7*\ UteJf Disclosing Party _ -
F£Ar\**-lrt F^EE/rlM llfaMfA6c£B? j
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, wilh any City elected official in the 12 months before the date this EDS is signed?
uycs xno^'ATa^lO emi^tA
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 Parly 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-profil 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 Parly must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business Relationship to Disclosing Parly Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantia! owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] No person directly or indirectly owns 10% or more ofthe 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 that agreement?
[ ] Yes [ ] No
B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("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 (he City, then the Disclosing Parly certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit.against an officer or employee ofthe Cily 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 Parly is a legal entity, all of those persons or entities dentificd 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 dale of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in conneclion with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violafion.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, slate or local) with committing any ofthe 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 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 lhat, 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 enlily following the ineligibility of a business enlity to do business with federal or slate 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 lhat 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 Enlity, 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 Parly, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agenls have, during the five years before the date this EDS is signed, or. wilh respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United Slates 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 thai 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 slate 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 ofthe U:S. Department of ihe 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 Parly is unable to certify to any ofthe above statements in this Pari 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 ofthe Disclosing Party who were, at any time during the 12-month period preceding the execution date of (his 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-monlh period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the Cily 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.
Al'A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ 3 is jKis 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:
"Wc are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge lhat none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. Wc understand that becoming a predatory lender or becoming an affiliate of a predator}' lender may result in the loss ofthe privilege of doing business with the Cily."
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
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed lhat the Disclosing Party certified 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 Pari D.|109|ill ilia ui iiei own name- 01 ui mc nuiiit ui any umoi jjtiouu i,
1. In accordance with Section 2-156-110 of the Municipal Code: Docs any official or employee of the Cily have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[]Yes
NOTE: If you checked "Yes" to Item D.l., proceed to Hems D.2. and D.3. If you checked "No" to ' Item D.I.,proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any othcT person or entity in the purchase of any property that (i) belongs to the Cily, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively, "City Properly Sale"). Compensation for properly taken pursuant to Ihe City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Docs the Mailer involve a City Property Sale?
¦ []Yes []No
If you checked "Yes" to Item D.l., provide the names and business addresses ofthe City officials or employees having such interest and identify the nature of such interest: .
Name Business Address Nature of Interest
4. The Disclosing Parly further certifies lhat 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 wilh Ihesc disclosure requirements may make any contract entered into with the Cily in connection with the Matter voidable by the City.
_/j>_l. The Disclosing Party verifies lhat 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 thai 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 ofinvestments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that lhc following constitutes full disclosure of all such records, including ihe 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 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 niade 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 lhat the Disclosing Party means lhat NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Mailer.)
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 lo cxlend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13
The Disciosing 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 Parly certifies that either: (i) it is nol an organization described in section 503 (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 19S6 but has not engaged and will nol 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 il 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 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 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 lo applicable federal regulations? (See 41 CFR Part 60-2.)
[JYes [] 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 []No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[]Yes [3 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 (hat:
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 wvvw.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 (hat 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 Parly's participation in Ihe Matter and/or declining to allow the Disclosing Party lo participate in other transactions wilh the City. Remedies at law for a false statement of material fact m ay 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 (he City lakes 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 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 longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants lhat:
a Page 11 of 13
F.l. The Disclosing Party is not delinquent in lhc 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 wafer 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 ("EPFS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Parly will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. 1. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that docs 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) arc true, accurate and complete as ofthe date furnished to the City.
~- , I, r"— — f~
(Sign here)
¦ j 1 t*
(Prim or type name of person signing)
\ Cv'-i IfrC
(Print or type title of person signing)
Commission expires:
Signed and sworn to before me on (date)
at _ C--QJ$~ County, _ T"! tVvii
OFFICIAL SEAL
CARMEN L VILLA >
Notary Public - State of Illinois >
My Commission Expires Apr 13, 2018 >
"w4
Pace 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 (he Applicant exceeding 7.5 percent. It is not (o 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 Parly" 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 (his EDS is signed, the Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the cily treasurer or any city department head as spouse or domestic paztner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in -law, mother-in-law, son-in-law, daughtcr-ih-Iaw, 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 UB. 1 .a., if the Disclosing Party is a corporation; all partners of the Disclosing Parly, if the Disclosing Parly is a general partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Parly is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Parly 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 ofthe legal entity to which such person is connected; (3) Ihe name and title ofthe elected cily official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?
[ ]Yes j>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 ofthe Municipal Code?
[ ] Yes [ JNo j\jNot 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 OFTHE ASSOCIATED EDS.
EXHIBIT A
An entity in which the Disclosing Party has an interest is the Landlord under a Lease with the City of Chicago as Tenant for the Independence Branch of the Chicago Public Library at 3548 West Irving Park Road, Chicago, Illinois.
An entity in which the Disclosing Party has an interest has submitted an application to vacate an alley located near the comer of Peterson and Albany Avenue, in Chicago, Illinois.
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I GENERAL INFORMATION
A. Legal name of the Disclosing Parly submitting this EDS. Include d/b/a/ if applicable:
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] the Applicant OR
2. J^a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Parly holds an interest: "jTrvr™ Zftzfkr** Wrfjv^^ ^*^_?_v'1
OR _ ' ¦ $\\L',s l.'3fJ l:5r|.Vy c*i>^«y
3. [.] a legal entity with a right of control (see Section II.B.L) Slate the legal name of the entity in
which the Disclosing Party holds a right of control:
Business address of the Disclosing Party: ^70\ K/' f^fepOO >
&ofg~*[
Telephone: Email: g"feA\*<^~^r^pe/fit?.C^Vtgf
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 properly, if applicable):
Q^^^SLU^^W^ 77 V
Which Cily agency or department is requesting this EDS?
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete Ihe 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 Party:
[ ] Person [ j 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
j>3 Trust. [] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
i i iryoU
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 [JNo []N/A
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
L 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 lilleholdeT(s).
If the entity is a general partnership, limited partnership, limited liability compan}', limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or enlity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit au EDS on its own behalf.
Name Title
_^tt^A_fifiiJ^|AL IX&SDEJE.
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
inicresl of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or olher similar entity. If none, slate "None." NOTE: Pursuant lo Section 2-154-030 ofthe Municipal Code ofChicago ("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
fi?o\ (Of^f U^^CYoAi^ DisclosingParty
ff*meL4_A_f&^ I l
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 Cily elected official in the 12 months before the date this EDS is signed?
If yes, please identify below the nanie(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 olher person or entity whom the Disclosing Parly 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 lo be paid. The Disclosing Party is not required lo 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 enlity 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 Cily whether disclosure is required or make the disclosure.
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Name (indicate whether Business Relationship to Disclosing Party Pees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly fate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
^^Chcck 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 ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes Vf 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 Paity submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Parly certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance wilh Article I is a continuing requirement for doing business with the City. NOTE: If Article 1 applies lo the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page A 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:
arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
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, stale or local) with committing any ofthe 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 Enlity" (meaning a person.or enlity that, directly or indirectly: controls the Disclosing Party, 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 entity to do business with federal or state or local government, including the Cily, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or enlity 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 Conlraclor or any Affiliated Entity or any olher official, agent or employee of the Disclosing Parly, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Parly, nor any Conlraclor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect lo a Contractor, an Affiliated Entity, or an Affiliated Enlily of a Contractor during the five years before the dale 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 State of Illinois, or any agency ofthe federal government or of any state or local government in the United Slates of America, in that officer's or employee's official capacity;
agreed or colluded with olher 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 Enlity or Contractor, or 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 (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 Stales 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 Parly understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
If the Disclosing Party is unable to certify lo any ofthe above statements in this PartB (Further Certifications), the Disclosing Party must explain below: A/I 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 lime 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 wilh "N/A" or "none"), jjt^
9. To the best of the 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 date of this EDS, to an employee, or elected or appointed official, ofthe Cily 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 Cily business and having a retail value of less than $20 perrecipient (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 ^Kis not
a "financial institution" as defined in Section 2-32-455(b) of Ihe Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Parly pledges:
"We are not and will nol 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 lhat becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business wilh the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-4 55(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):
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements,
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same meanings when used in this Part D,
1. In accordance with Section 2-156-110 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 8ny other person or entity in the Matter?
[jYes
NOTE: If you checked "Yes" to 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 lhat (i) belongs to ihe City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the Gity (collectively, "City Properly 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?
- []Yos [JNo
If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing 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 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 Ciiy in connection with the Matter voidable by the City.
. The Disclosing Party verifies mat the Disclosing Parly has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records ofinvestments 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 ofinvestments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies lhat 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 federaliy funded, proceed to Section VII. For purposes of this Section VI, lax credits allocated by the City and proceeds of debt obligations ofthe Cily are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Aci 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 ihe letters "NA" or if the word "None" appear, it will be conclusively presumed lhat 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 to pay any person or entity listed in Paragraph A.J. 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 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 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 Parly must maintain all such subcontractors' certifications for the duration of the Mailer and must make such certifications promptly available to the Cily 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 [3 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? (Sec 41 CFR Part 60-2.)
[ 3 Yes [3 No
Have you filed with the Joint Reporting Committee, the Director of (he Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
? Yes [3 No
Have you participated in any previous contracts or subcontracts subject (o the equal opportunity clause?
[ 3 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 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 materia] inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Parly understands that it must comply with all statutes, ordinances, and regulations on which (his 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.cityofchicafio.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 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 Cily 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 Aci request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which if may have against the City in connection with the public release of information contained in (his EDS and also authorizes the City to verify Ihe accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In lhc event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Mailer. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 ofthe Municipal.Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-1 54-020 ofthe Municipal Code.
The Disclosing Party represents and warrants lhat:
Page 11 of 13
F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection wilh 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 ofthe City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any ofthe ilems 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 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)
By: c-/f ~}A rJs J ,V. \^Au/.,tZ^ g-^
(Sign here) i
(Print or type name of person signing)
(Print or type title of person signing)
Signed and sworn to before me on (date) _
at __C Or0j<^ County,*]ldUj/WL/_&_ (state).'
Commission expires: ^~f-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 ro he completed only by (a) the. Applicant, and (1)) 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, 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 ofthe Disclosing Party, if the Disclosing Partyis 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 DisclosingParty, if the Disclosing Party is a limited liability company; (2) all principal officers ofthe 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 secretaiy 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) die 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 SCOFFLAYV/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It-is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of theMunicipal
Code?
[ jYes
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant lo Section 2-92-416 ofthe Municipal Code?
[ ]Yes
3. If yes to (1) or (2) above, please identify below the name of the person or legal entity
identified as a building code scofflaw or problem landlord and ihe 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.
EXHIBIT A
An entity in which the Disclosing Party has an interest is the Landlord under a I -ease with the City of Chicago as Tenant for the Independence Branch ofthe Chicago Public Library at 3548 West Irving Park Road, Chicago, Illinois.
An entity in which the Disclosing Party has an interest has submitted an application to vacate an alley located near the corner of Peterson and Albany Avenue, in Chicago, Illinois.
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 ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. a legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthe
Applicant in which the Disclosing Party holds an interest:_/-ri/)r*a
or ULUu £y
Q7o\ w^ fe:
3. [ ] a legal entity with a right of control (see Section II.B.L) State the legal name ofthe enlily in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Parly:
C. Telephone: m'27\m^ ¦ Fax: m~Z7te\77k Email: ^Q^^ T^Li-r^ -
D. Name of contact person:
E. Federal Employer Identification No. (if you have one):;
F. Brief description of contract, transaction or other undertaking (referred lo below as ihe "Matter") to
which this EDS pertains. (Include nroiecLn umber and location of properly, if applicable):
o, GV\»^r> p.,/U\'c Ui i?r^ry-
G. Which Cily agency or department is requesting this EDS?-fcg|^f. Pll£~/tjf fVci ij> /^tyi
If the Mailer 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 of the Disclosing Party:
[ J 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))?
[ 3 Limited partnership [ ] Yes [ 3 No
Trust [ 3 Other (please specify)
2. For legal entities, the slate (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 Stale of Illinois as a foreign entity?
[3 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 arc no such members, write "no members." For trusts, estates or other similar entities, list below the legal tillcholder(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-lo-day management ofthe Disclosing Purty. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name . Title
.bcWvA ry'.ejyr-vx'rN -"Tr^teg-
2. Please provide the following information concerning each person or entity having a direct ot 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 ofChicago ("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
^ . r- £70 ( W. feW«*-Ave... DisclosingParty^
Dayl<\ vVigd^Mii _Cbi^±Jf^^k_i!^_J
SECTION III -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Parly had a "business relationship," as defined in Chapter 2-156 of theMunicipal Code, with any City elected official in the 12 months before the date this EDS is signed?
If yes, please identify below the namc(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 Parly 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.
(A dd sheets if necessary)
Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantia! owners of business entities lhat 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 Jfc^No [J No person directly or indirectly owns 10% or more of the
Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[jYes [JNo
FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Parly submitting this EDS is the Applicant and is doing business with the City, then.lhe Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged wilh, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE; If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
2. The Disclosing Parly and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section H.B.1. 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 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) wilh committing any of Ihe offenses set forth in clause B.2.b. of (his Section V;
have not, within a five-year penod 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 stale, or any other unit of local government.
3. The certifications in subparts 3, 4 and 5 concern:
• the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited lo 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 wilh 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 (he 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 Enlity 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 Part}', 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 Cily, the State of Illinois, or any agency of the federal government or of any state or local government in the United Stales of America, in that officers 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
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 slate 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 ofthe following lists maintained by the Office of Foreign Assets Control of 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 Enlity List and the Debarred List.
The Disclosing Parly understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of (he Municipal Code.
If the Disclosing Parly is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below: A A
Pago 6 of 13
If the letters "NA," the word "None," or no response appears on the lines above, il will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Parly who were, al any time during the 12-month period preceding the execution dale of this EDS, an employee, or elected or appointed official, of Ihe City ofChicago (if none, indicate with "N/A" or "none").
9. To the best of the Disclosing Parly's knowledge after reasonable inquiry, the following is a complete list of all gifts that, the Disclosing Parly has given or caused 1o be given, at any time during the 12-monlh period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of Ibis statement, a "gift" does 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 $20 per recipient (if none, indicate with "N/A" or "none"). As lo any gift listed below, please also list the name of the City recipient.
-JVjA
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ 3 is {>rjfis not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will nol become a predatory lender as defined in Chapter 2-32 of Ihe Municipal Code. We further pledge lhat none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand thai becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of lhc Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
Page 7 of 13
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
In accordance wilh Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Mailer? I i p i . \ r,
[jYes j^Ncfo -vta Wf koox/lei^a 0'i$c\ as, *vj Tart/.
NOTE: If you checked "Yes" lo Ilem D.l., proceed to Items D.2. and D.3. If you checked "No" lo Hem 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 lhat (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process al the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does nol constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[]Ycs
3. If you checked "Yes" to Hem D.L, provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Business Address
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 Parly 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 wilh the City in connection wilh the Matter voidable by the City.
^\ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records ofinvestments or profits from slaver)' 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 Parly has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Parly has found records ofinvestments 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 lo th e 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 Aci 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 federall}' 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 Parly will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A.l. and A.2. above.
The Disclosing Party certifies lhat either: (i) it is not en organization described in section 501 (c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 503(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors'certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[]Yes []No If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant lo applicable federal regulations? (Sec 41 CFR Part 60-2.)
[ ] Yes [ ] 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 [ ] No
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
[ ] Yes [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the Cily in connection with the Matter, whether procurement, 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.orfi/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suile. 500, Chicago, IL 60610, (31.2) 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 Parly'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.
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 inforrnatiort contained in this EDS and also authorizes the Cily to verify the accuracy of any information submitted in (his EDS.
The information provided iu this EDS must be kept current. In the event of changes, the Disclosing Parly must supplement this EDS up to the time the City takes action on the Mailer. 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 tor certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
F.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 lo the Cily. This includes, but is not limilcd 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 Parlies List System ("EPLS") maintained by (he 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 nol, without the prior written consent of the City, use any such contractor/subcontractor that docs 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 lo this EDS.
CERTIFICATION
Under penally of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants lhat all certifications and statements contained in this EDS and Appendix A (if applicable) arc true, accurate and complete as of the date furnished to the Cily.
(Print or type name of Disclosing Party)
(Sign here)
(Print or type name of person signing)
(Print or type title of person signing)
Page 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
Thfs 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 Parly" 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 lo the mayor, any alderman, the city clerk, the city treasurer or any cily 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 slepsister 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 ofthe Disclosing Party, if the Disclosing Parly is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ jYes
If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title of the elected eityofficial or department head to whom such person has a familial relationship, and (4) lhc 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 inleresl in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of theMunicipal
Code?
KjNo
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of theMunicipal Code?
[ ]Yes
3. If yes to (1) or (2) above, please identify below the name of the person or legal entity
identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OFTHE ASSOCIATED EDS.
EXHIBIT A
An entity in which the Disclosing Party has an interest is the Landlord under a Lease with the City ofChicago as Tenant for the Independence Branch ofthe Chicago Public Library at 3S48 West Irving Park Road, Chicago, Illinois.
An entity in which the Disclosing Party has an interest has submitted an application to vacate an alley located near the corner of Peterson and Albany Avenues in Chicago, Illinois.
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 applicable:
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. a legal entity holding a direct or indirect interest in the Applicant. State the legal name ofthe
Applicant in which the Disclosing Parly holds an interest: %rv\w .CY^er/^n Y^nXg--
3. [ ] a legal entity with a right of control (sec Section I1.T3.1.) Slate the legal name of the enlity in
which the Disclosing Party holds a right of control:
B. Business address ofthe Disclosing Parly
Telephone: '7_L.£. :?SlH13l\ Fax: lTl:22izBLL^ Email: iArfet
Name of contact person:
E. Federal Employer Identification No. (if you have one): j_
which this EDS perVains. (Include project number and Ipcatian ofproperty, if applicable):
^
G. Which City agency or department is requesting this EDS?£)frp/ ¦ 0~f 0X^^l' h"j"' ^D^
If Lhc 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 H - DISCLOSURE OF OWNERSHIP INTERESTS
A. MATURE OF THE DISCLOSING PARTY
Parly:
[ ] Limited liability company
[ ] Limited liability partnership
[3 Joint venture
f ] Not-for-profit corporation
(Ts the not-for-profit corporation also a 501(c)(3))?
[JYes fJNo [ j Other (please specify)
For legal entities, the.state (or foreign country) of incorporation or organization, if applicable:
2. for legal entities not organized in the State of Illinois: Has the organization registered to do business in the Stale of Illinois as a foreign entity?
(3 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 arc legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal litleholder(s).
rf the enlily is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title ofeach general partner, managing member, manager or any other person or enlity 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.
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
mleresl oi' a member or manager in a limilcd liability company, or interest of a beneficiary of a imsL
estate'or other similar entity. If none, state "None." NOTE: Pursuant lo 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 Addresser t„ Percentage Interest in the
,1 [vt r'.\ Q.?o\ w. re v?^-- - ^ DisclosingParty p
Jli£lW_J"w cVa;^ ix. £fi*5*v s„\j 9^*
SECTION !H - 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?
1 j Yes ]^No
If yes, please, identify below the name(s) of such Cily elected official(s) and describe such rclationship(s):
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
"\ he DisclosingParty must disclose the name and business address ofeach subcontractor, attorney, lobbyist accountant, consultant and any other person or entity whom, the Disclosing Parly 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-esti.matcd to be paid The Disclosing Party is.nol 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 anyperson 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 Parly must either ask the City whether disclosure, is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business Relationship lo 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)
£4 Check, here if ihe Disclosing Party has nol 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 lhc City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes J^No [ J 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?
I JYes [JNo
FURTHER CERTIFICATIONS
';. 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 wilh, oi 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, penury, 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 fivc-ycar compliance tirnefnimes in certifications 2 and 3 below.
Page 4 of 13
2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l. of this EDS:
». .ire not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government:
h. hp. ve nol. 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 apublic transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
c arc not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, slate or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
d. 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
c 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 auy other unit of local government.
3. The certifications in subparts 3,4 and 5 concern:
*¦ the Disclosing Party;
" any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Parly in connection with the Matter, including but nol limited to all persons or legal entities disclosed under Section TV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Enlily" (meaning a person or entity that, directly or indirectly: controls the Disclosing Parly, is controlled by the Disclosing Parly, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limita tion : interlocking management or ownership; identity of interests among family members, shared facilities nnd equipment; common use of employees; or organization of a business entity following the ^eligibility of a business entity to do business wilh federal or state or local government, including the Cily. using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, Ihe 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 Parly, any Contractor or any Affiliated Entity or any jther official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Enlity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of cither the Disclosing J'ariy or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Conlraclor, an Affiliated Enlity, 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 tho Matter:
ii bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting lo bribe, a public officer or employee ofthe City, Ihe 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
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).
4. 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 slate or ofthe United States of America that contains the same elements as the offense of bid-rigging or bid-relating.
:• . Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists iiiitiutaiued by the Office of Foreign Assets Control ofthe 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, ihe Unverified List, the Entity List and the Debarred List.
o. The Disclosing Parly understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe Municipal Code.
7. Jf the Disclosing Party is unable to certify to any ofthe above statements in.Ibis Part B (Further Certifications), the Disclosing Parly must explain below:
Page 6 of 13
If lhc letters "NA." lhc word "None," or no response appears on the lines above, it will be conclusively presumed thai Ihe Disclosing Parly certified lo the above statements.
S. 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-monlh period preceding the execution date of this EDS, an employee, or elected or appointed official, of lhc Cily of Chicago (if none, indicate with "N/A" or "none"). 4 // 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-monlh period preceding lhc execution date of this EDS, to an employee, or elected or appointed official, of the City ofChicago. For purposes of this slalcmcnl, a "gift" does nol include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in lhc 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 lisl the name ofthe Cily recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
1. The Disclosing Party certifies that lhc Disclosing Party (check one)
[Jis
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:
"Wc 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 ChapleT 2-32 ofthe Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
If the Disclosing Party is unable to make this pledge because il or any of its affiliates (as defined in Section 2-32-455(b) of lhc 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 the ieUers "N A," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified lo the above statements.
(JYes pQ-No To-t-W Kvwwjc^ o\ ^wv,c,\^y^y
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to llcni 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 iii the name of •my other person or entity in the purchase of any property lhat (i) belongs to the City, or (ii) is sold lot laxcs or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Pr operty 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? I' 1 Yes [JNo
3 U you checked "Yes" to Item D.lprovide 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. i he 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 wilh these disclosure requirements may make any contract entered into with (he City in connection wilh the Matter voidable by the Cily.
/N —1 "i"'ie 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 theii slaves), and the Disclosing Parly has found no such records.
2. The Disclosing Parly 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 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, lax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
¦ fisi below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf ofthe Disclosing Party with respect lo the Mailer: (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, ii will be conclusively presumed lhat the Disclosing Parly means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Parly wilh 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 enlity 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 ol" Congress, in connection wilh 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.
Tagc9 of 13
-'5. The Disclosing Party will submit an updated certification at the end ofeach 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 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 not engaged and will nol engage in "Lobbying Activities".
1! ihe 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 wilh their bids or in writing al the outset of negotiations.
Is lhc Disclosing Parry the Applicant?
t]Yes []No
If "Yes," answer the three questions below:
;. Have you developed and do you have on file affirmative action programs pmsuant to applicable federal regulations? (Sec 41 CFR Part 60-2.) UYes f]No
rfiive you filed Wilh 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?
1 ] Yes I ] No
3. Have you participated iu any previous contracts or subcontracts subject to the equal opportunity clause?
[]Ycs [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;
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant aud the City in connection with the Matter, whether procurement. City assistance, or olher City action, and are material inducements to Ihe.City's execution of any contract or taking other action with respect to the Mailer. The Disclosing Party understands thai it must comply with all statutes, ordinances, and regulations on which this EDS is based.
ii. 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 al w vvw.cityofchicago.org/Elhics, 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.
C Sf the Cily 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 voidablc, and lhc 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.
D. K is the City's policy to make this document available lo the public on its Internet site and/or upon request. Some oi 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 olh«r.w isc. 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 lo 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, lhc Disclosing Party must supplement this EDS up to the time the City takes action on the Mailer. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Parly must update this HDS as the contract requires. NOTE: With respect to Mailers subject to Article 1 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 Parly represents and warrants that:
Page 11 of 13
r.l. The Disclosing Pauy is not delinquent in the payment of any tax administered hy 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 (he Cily. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales laxes.
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 wilh the N4attcr certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent ofthe City, use any such contractor/subcontractor that docs 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., 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 thai all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete us ofthe date furnished to the City.
a
(Print or type rumip i*f Dkclosing PaiW)^
Bv:
(Sign here)
(Print or type name of person signing)
(Print or type title of person signing)
Signed and sworn to before me on (date)
at Ca O^C County, _t£J^S „'(stati).
. _ Notary Public.
Commission expires:
d&jj.L.
^mii^Siilffli i-fti i-ftiiir^*
OFFICIAL SEAL CARMEN L VILLA Notary Public - State ol Illinois My Commission Expires Apr 13. 2018
Hii iyn ngi quil i qjjim^jEM&y ^P"B| '¦
Pane 12 of 13
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
Tints Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in lhc Applicant exceeding 7.5 percent, lt is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
I hidcr Municipal Code. Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party 'Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section ILB.t .a., if the Diselosing Party is a corporation; all partners ofthe DisclosingParty, if the Disclosing Party is a genera) partnership: all general partners and limited partners of lhc 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 ofthe 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.
Docs tiie 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?
[ 1 Yes }XfNo
! f yes, please identify below (1) the name and title of such person, (2) the name of the legal enlily to which tsuch 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 legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"), "tt 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 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal
Code?
KjNo
2 if the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?
[ ]No
[ JYes
3 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 ofthe building or buildings to which the pertinent code*violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNO>YLEDGMENT AND AGREEMENT THAT THIS APPENDIX li 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.
ESilBJIA
An entity in which the Disclosing Party has an interest is the Landlord under a Lease with the City ofChicago as Tenant for the Independence Branch ofthe Chicago Public Library at 3548 West Irving Park Road, Chicago, Illinois.
An entity in which the Disclosing Party has an interest has submitted an application to vacate an alley located near the corner of Peterson and Albany Avenues in Chicago, Illinois.
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