ORDINANCE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1: On behalf of the City of Chicago as Landlord, the Commissioner of the Department of Fleet and Facility Management is authorized to execute a Lease Amendment with Erie Family Health Center, Inc., as Tenant, to permit an extension of the Term through December 31, 2026 and the expansion of the leased premises from approximately 15,943 to 16,272 square feet for the property located at 2418 West Division Street; such Lease Amendment to be approved by the Commissioner of the Department of Public Health and approved as to form and legality by the Corporation Counsel in substantially the following form:
SECOND AMENDMENT TO LEASE
THIS SECOND AMENDMENT TO LEASE (the "Second Amendment") is made and
effective as of , 2016 (the "Commencement Date") by and between CITY
OF CHICAGO, a Municipal Corporation and Home Rule Unit of Government (the "City" or "Landlord") and ERIE FAMILY HEALTH CENTER, INC., an Illinois not-for-profit corporation ("Tenant").
RECITALS
WHEREAS, on July 1, 2012, Landlord and Tenant executed Lease No. 20253 (the "Lease") governing Tenant's use of approximately 11,310 square feet of office and clinical space (the "Original Premises") located in the Westtown Neighborhood Health Center at 2418 West Division, Chicago, Illinois for a Term through July 1, 2019; and
WHEREAS, on October 1, 2015, Landlord and Tenant executed the First Amendment to the Lease (the "First Amendment") which expanded the Original Premises to include an additional 4,633 square feet of space (the Original Premises and the expanded premises together, the "First Amended Premises"); and
WHEREAS, Tenant uses the First Amended Premises to provide health services consistent with Tenant's not-for-profit purposes and so as to lessen the burdens of government by providing such health care services; and
WHEREAS, Tenant has received a federal grant from the Health Resources and Service Administration (the "HRSA") to fund improvements to Tenant's clinic at 2418 West Division; and
WHEREAS, as part of the HRSA grant process, Landlord and Tenant wish to amend the Lease to expand the First Amended Premises, extend the Term of the Lease, and include certain provisions required by the HRSA.
NOW THEREFORE, in consideration of the above recitals, and mutual promises, covenants, rights and obligations herein contained, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Landlord and Tenant mutually agree as follows:
Recitals and Terms of Art. The foregoing recitals are hereby incorporated into and made a part of this Second Amendment by this reference. All capitalized terms in this Second Amendment shall have the same meaning ascribed thereto in the Lease, unless otherwise provided herein.
Expansion of First Amended Premises. The First Amended Premises are hereby expanded to include an additional 329 square feet of space (the "Expansion Premises"), which is adjacent to the First Amended Premises, as depicted on Exhibit
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A attached hereto. Tenant's total leasehold at 2418 West Division, including the First Amended Premises and the Expansion Premises, shall be 16,272 square feet (the . "Revised Premises").
Condition of Expansion Premises. Tenant shall accept the Expansion Premises in as-is condition without any improvements to be undertaken by the Landlord.
Use of Expansion Premises. Tenant shall use the Expansion Premises only as clinical and office space for the delivery of health services consistent with Tenant's not for profit mission.
Term. The term of the Lease is extended to December 31, 2026.
Alterations, Additions, and Improvements. Tenant has received HRSA grant funding to undertake certain alterations, addition, and improvements within the Revised Premises. Landlord acknowledges that such alterations, additions, and improvements are critical for Tenant's services. Tenant may make such alterations, additions, and improvements within the Revised Premises. Any such alterations, additions, and improvements shall be in full compliance with all applicable laws, permit requirements, and building codes. Tenant must obtain the prior written consent of the Commissioner of the Department of Fleet and Facility Management before commencing any alterations, additions, or improvements. Landlord shall not unreasonably withhold, delay, or condition such consent. Any permanent alterations, additions and improvements to the Revised Premises shall be without cost to Landlord and shall become property of Landlord at termination of the Lease without offset or other credit to Tenant.
Proportionate Use. Tenant's Proportionate Use of the Building shall be increased to 74.49%. This Proportionate Use is based on the square footage of the Revised Premises (16,272) divided by the total square footage of 2418 West Division (21,846).
Operating Costs. Tenant's obligations for Operating Costs are revised as follows:
Beginning on January 1, 2017, Tenant shall pay Landlord the amount of Six Thousand One Hundred Twenty Three and 04/100 Dollars ($6,123.04) per month in Operating Costs for use of the Revised Premises. This is based on Tenant's Proportionate Use of the actual 2015 Operating Costs for the Building, which is further detailed in Exhibit B attached hereto.
Each subsequent year of the Term, the Operating Costs will increase by three percent (3%).
Annual accounting adjustments will no longer be conducted.
The revised schedule of Operating Costs is further detailed in Exhibit B.
Holding Over. Any holding over by Tenant shall be construed to be a tenancy from month to month beginning on January 1, 2027, and Tenant will pay a ten percent (10%) increase in monthly Operating Costs. During such holding over all other provisions of the Lease shall remain in full force and effect.
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Assignment. Tenant is prohibited from assigning the Lease or subleasing the Revised Premises.
Notice. Landlord will notify HRSA, at the address below, of any Tenant default under the provisions of the Lease:
[HRSA notice address]
Opportunity to Cure. HRSA will have sixty (60) days to cure any default on the part of Tenant, and the Landlord will not exercise any remedies until after the sixty (60) cure period. HRSA may intervene on behalf of Tenant, or another recipient named by HRSA, to ensure the default is cured. Landlord shall accept performance, including payment, from HRSA's designee for Tenant as if such performance had been made by Tenant.
Replacement of Tenant. HRSA shall have the right to designate a replacement for Tenant, subject to approval of the City Council of the City of Chicago, for the balance of the Term in the event of Tenant's default, termination of the HRSA grant, or vacation of the Revised Premises by Tenant.
Recording of Lease. Landlord agrees to the recording of the Lease, including any amendments, in the land records of the jurisdiction where the property is situated.
Federal Interest. Landlord acknowledges there will be a federal interest in the Revised Premises as a result of the proposed improvements and Landlord agrees to the recording of a Notice of Federal Interest in the Revised Premises in the form attached hereto as Exhibit C.
Incorporation into Lease No. 20253. This Second Amendment shall be incorporated into the Lease as executed by Landlord and Tenant on July 1, 2012. Unless otherwise expressly provided herein, all other provisions of the Lease shall remain in full force and effect and shall be applicable to this Second Amendment and to the Expansion Premises. Unless expressly provided herein, if there is a conflict between the terms and conditions of the Lease and the terms and conditions of the Second Amendment, the terms and conditions of this Second Amendment shall prevail.
Counterparts. This Second Amendment may be executed in multiple counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument.
(SIGNATURES APPEAR ON THE FOLLOWING PAGE]
|1010|IN WITNESS WHEREOF, the parties have executed this Second Amendment to Lease as of the day and year first above written.
LANDLORD:
THE CITY OF CHICAGO,
an Illinois Municipal Corporation and Home Rule Unit of Government
DEPARTMENT OF PUBLIC HEALTH
Commissioner
DEPARTMENT OF FLEET AND FACILITY MANAGEMENT
Commissioner
APPROVED AS TO FORM AND LEGALITY: BY: DEPARTMENT OF LAW
Deputy Corporation Counsel Real Estate Division
ERIE FAMILY HEALTH CENTER, INC.,
an Illinois not-for-profit corporation
By:
Name: Its:
|101010|EXHIBIT A
EXHIBIT B
SCHEDULE OF OPERATING COSTS
Commencing January 1, 2017, Tenant's monthly Operating Costs shall be $6,123.04, based on the following calculation:
2015 ACTUAL OPERATING COSTS
2418 West Division Street - Westtown Health Clinic
(subject to further revisions)
Items
Utilities
Security
Custodial
Engineering
Other Operating Costs
Building Amounts (21.846 Sq. Ft.)
(tenant provides) (tenant provides)
$60,640.66 $0.00 $0.00 $12,368.29 $25,636.70
Total Annual Costs
Annual Costs x (Premises s.f. / Building s.f.) = Tenant's Annual Operating Costs $98,645.65 x (16,272 s.f. 7 21,846 s.f.) = $73.476.24
The Operating Costs shall increase three percent (3%) on January 1 of each year throughout the Term:
Schec ule of Operating Costs
Year Annual Rate Monthly Rate
2017 $73,476.24 $6,123.02
2018 $75,680.53 $6,306.71
2019 $77,950.94 $6,495.91
2020 $80,289.47 $6,690.79
2021 $82,698.16 $6,891.51
2022 $85,179.10 $7,098.26
2023 $87,734.47 $7,311.21
2024 $90,366.51 $7,530.54
2025 $93,077.50 $7,756.46
2026 $95,869.83 $7,989.15
|1010|Exhibit C
NOTICE OF FEDERAL INTEREST
On December 14, 2012, the Health Resources and Services Administration's Bureau of Primary Health Care awarded Grant No. C12CS25610 to Erie Family Health Center ("Erie"). The grant provides Federal funds for alteration and renovation of Erie Division Street and Teen Health Centers located at 2418 W. Division St., Chicago, IL 60622-2940 (the "Property"). The City of Chicago is the owner of the Property. Erie.is a tenant at the Property, and Erie operates the Erie Division Street and Teen Health Centers within its leasehold interest of 16,272 square feet of space (the "Premises") at the Property, pursuant to that certain lease dated July 1, 2012, as amended (the "Lease"). Erie Division Street and Teen Health Centers provide primary health care services to 12,361 patients through over 54,000 patient visits annually, regardless of a patient's ability to pay. Through this project, Erie will demolish and renovate 4,000 square feet of the Premises to include: 7 exam rooms, 1 larger treatment room, 1 lab, a waiting area with three registration stations, a centralized care station with a nurse and additional space for medical assistants, private consultation space adjacent to the waiting room, and offices for behavioral health, case management, and WIC services. The Property is legally described as follows:
Lots 8 through 32 in block 8 of blocks 5, 6, 7 & 8 of Winslow & Jacobson's subdivision of the southeast ]A of the northeast % of Section 1, Township 39 North, Range 14, east of the third principal meridian in Cook County Illinois.
Permanent Index Numbers: 16-01-229-014, 16-01-229-015, 16-01-229-016, 16-01-229-017, 16-01-229-030, 16-01-229-031, 16-01-229-032, 16-01-229-033, 16-01-229-034, 16-01-229-040, 16-01-229-046, 16-01-229-047, 16-01-229-048, 16-01-229-049, 16-01-229-050
Address: 2418 W. Division St., Chicago, IL 60622-2940
The Notice of Grant Award for this grant includes conditions on use of the Premises and provides for a Federal interest in the Premises. Specifically, the Premises may not be (1) used for any purpose inconsistent with the statute and any program regulations governing the award under which the Premises were renovated; (2) mortgaged or otherwise used as collateral without the written permission of the Associate Administrator, Office of Federal Assistance Management ("OFAM"), Health Resources and Services Administration ("HRSA"); or (3) sold or transferred to another party without the written permission of OFAM, HRSA. These conditions are in accordance with the statutory provisions set forth in the Patient Protection and Affordable Care Act, P.L. 111-148 Patient Protection and Affordable Care Act of 2010, Title IV, §4101 (P.L. 111-148), Title 45 CFR part 74 or 92 as applicable, the HHS Grants Policy Statement, and other terms and conditions of award.
These grant conditions and requirements cannot be nullified or voided through a transfer of ownership. Therefore, advance notice of any proposed change in usage or ownership must be provided to the Associate Administrator, OFAM, HRSA.
The Federal interest in the Premises shall terminate upon the termination of the Lease.
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Signature of Property Owner:
Typed Name:
Title:
Date:
On this the day of , 2016, before me the undersigned, a Notary Public for the State of
Illinois at Large, personally appeared before me and is known to be the person who executed this instrument on behalf of the City of Chicago.
Witness my hand and official seal.
SWORN AND CONFIRMED TO BEFORE ME THIS DAY OF
, 20
Signature of Notary Public
County / State
My Commission Expires (Date) Notary Seal:
|1010|2418 W. Division Street Lease No. 20253
SECTION 2: This Ordinance shall be effective from and after the date of its passage and approval.
OFFICE OF THE MAYOR
CITY OF CHICAGO
RAHM EMANUEL
MAYOR
September 14, 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 an ordinance authorizing an amendment to a lease agreement with Erie Family Health Center.
Your favorable consideration of this ordinance will be appreciated.
Very truly yours,
Mayor
JOSEPH A. MOORE
Alderman. 49th Ward 7356 North GreenviewAvenue Chicago. Illinois 60626 telephone 773-338-5796 ward49@cityofchicago org www ward49 com
CITY COUNCIL
CITY OF CHICAGO COUNCIL CHAMBER
City Hall, Room 200 121 North LaSalle Street Chicago. Illinois 60602 Telephone 312-744-3067
COMMITTEE MEMBERSHIPS
HOUSING AND REAL ESTATE
Chairman
Budget and Government Operations
Committees. Rules and Ethics
Education and Child Development
Finance
Health and Environmental Protection
Human Relations
Special Events, Cultural Affairs and Recreation
October 5, 2016
To the President and Members of the City Council:
Your Committee on Housing and Real Estate, for which a meeting was held on September 29, 2016, having had under consideration the ordinance introduced by Mayor Rahm Emanuel on September 14, 2016, this being the lease amendment with Erie Family Health Center, Inc. at 2418 W. Division St., begs leave to recommend that Your Honorable Body Approve said ordinance transmitted herewith.
This recommendation was concurred in by a voice vote of all committee members present with no dissenting votes.
seph A. Moore, Chairman :ee on Housing and Real Estate
Respectfully submitted,
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing
arty submitting4his EDS. Include d/b/a/ if applicable:
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: 1 .~^>£jhe Applicant OR
2. [] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [ ] a legal entity with a right of control (see Section II.B. 1.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
77 01 1/vJ- pjfe&Qii
Telephone: (M)^'^^**: [3j Y^mail: J fflrfftN) \^Pf\^(tm [l \fa[
D. Name of contact person: _
E. 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):
Extension of lease term for lease of City-owned property located at 2418 W. Division St.
Which City agency or department is requesting this EDS? Dept. of Fleet & Facility Management
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
Page 1 of 13
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
[ ] Limited liability company [ ] Limited liability partnership [ ] Joint venture "^^Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?
V[Ycs [ ] No
[ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
11
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[ ] Yes [ ] No ^xfN/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 titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.
ime
Name
Ate [£Cn(Xj
>(Ut
2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13
interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.
Name Business Address Percentage Interest in the
Disclosing Party
SECTION III -- BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?
[]Yes yl^o
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 of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 13
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
>f^Check here if the Disclosing Party has-not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [ ] No 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?
[ ] Yes [ ] No
FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.
Page 4 of 13
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B. 1. of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;
have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The certifications in subparts 3, 4 and 5 concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity" to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 13
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.
The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.
Page 6 of 13
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:
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is J^vf not
a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. 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."
Page 7 of 13
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.
In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ] Yes J^^°
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to Item D.l., proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes J>£No
If you checked "Yes" to Item D.l., provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:
Name Business Address Nature of Interest
4. The Disclosing 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 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.
^y^CJ ¦ The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
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):
M/A -
(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.)
The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. 1. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
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. 1. and A.2. above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501 (c)(4) of the Internal Revenue Code 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 subcontracted 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?
[]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.)
[]No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[]No
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
K^Yes [ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:
Page 10 of 13
SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and.the City in connection with the Matter, whether procurement, City assistance, or other City action, and arc material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13
F.l. The Disclosing Party is not delinquent in 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 to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. 1. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.
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(Print or type/name of Disclosing Party)
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(Print or type name of person signing) (Print or type title of person signing)
Signed and sworn to before me on (date)
"OFFICIAL SEAL-MARIA J. ROCHA NOTARY PUBLIC, STATE OF ILLINOIS My Commission Expires Aug. 25,2017
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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 to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ] Yes
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 13
' CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Sect ion 2-92-416 of the Municipal
Code?
[ ]Yes
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?
[ ]Yes
3. If yes to (1) or (2) above, please identify below the name of the person or legal entity
identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.
FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.