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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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Redevelopment agreement with Ogden Washtenaw JV LLC for grant and expenditure of Neighborhoods Opportunity Funds at 2632 W Ogden Ave, 2638 W Ogden Ave and 2646 W Ogden Ave
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Topic:
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AGREEMENTS - Redevelopment, - FINANCE FUNDS - Neighborhoods Opportunity Fund
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Attachments:
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1. O2019-2578.pdf
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OFFICE OF THE MAYOR CITY OF CHICAGO RAHM EMANUEL MAYOR March 13.2019 TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO Ladies and Gentlemen: At the request ofthe Commissioner of Planning and Development, I transmit herewith ordinances authorizing the execution of redevelopment agreements involving expenditure of Neighborhoods Opportunity Funds. Your favorable consideration of these ordinances will be appreciated. Mayor Very truly yours, ORDINANCE WHEREAS, the City of Chicago (the "City") is a home rule unit of government under Article VII, Section 6(a) of the Constitution of the State of Illinois, and as such may exercise any power and perform any function pertaining to its government and affairs; and WHEREAS, the City is authorized under its home rule powers to regulate the use and development of land; and WHEREAS, Chapter 16-14-010 et seg. of the Municipal Code of Chicago, as amended (the "Code") contains the Neighborhoods Opportunity Fund Ordinance (the "NOF Ordinance") establishing the Neighborhoods Opportunity Fund (the "NOF"); and WHEREAS, the purpose of the NOF is to (a) promote growth within the downtown area through the floor area bonus provisions of Section 17-4-1000 of the Code, and simultaneously generate new revenues for investment in business development and job growth in neighborhoods impacted by poverty, high unemployment, and other indicators of economic deprivation; (b) strengthen neighborhood commercial corridors in qualified investment areas; and (c) address the decline of private investment in qualified investment areas that damages the City's overall economic competitiveness, impedes the sustainable and equitable development of the City as a whole, contributes to inequality and poverty, and has a detrimental effect on the City's quality of life; and WHEREAS, the NOF shall be used for projects located in or directly benefiting qualified investment areas, as indicated on a map published by the Commissioner (the "Commissioner") of the Department of Planning and Development ("DPD") and updated at least once every five years; and WHEREAS, the authorized uses of the NOF are for eligible costs (as defined in the NOF Ordinance) related to (a) commercial establishments that provide, on a permanent or short term (pop up) basis, goods and services which complement and revitalize the areas in which they are located, and which may include, without limitation, grocery stores, retail establishments, and restaurants that sell food primarily for consumption on premises; (b) cultural establishments that provide, on a permanent or short term (pop up) basis, recreational and educational opportunities which complement and revitalize the areas in which they are located; and (c) incubation, mentoring, and training of small businesses that otherwise qualify as authorized uses under (a) or(b)above; and WHEREAS, DPD has determined that the applicant named in Exhibit A attached hereto (the "Grantee") meets the requirements of the NOF Ordinance and is eligible to receive a NOF grant for the project described in Exhibit A, in the amount and under the terms and conditions set forth in Exhibit A (the "Grant"); and WHEREAS, DPD has recommended that the City Council of the City approve the Grant to the Grantee, now, therefore, BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. The above recitals are expressly incorporated in and made a part of this ordinance as though fully set forth herein. SECTION 2. The Commissioner and a designee of the Commissioner (collectively, the "Authorized Officer") are each hereby authorized, subject to approval by the Corporation Counsel, to enter into and execute a redevelopment agreement with the Grantee and to execute such agreements and instruments, and perform any and all acts as shall be necessary or advisable in connection with the implementation of the Grant. The execution of such agreements and instruments and the performance of such acts shall be conclusive evidence of such approval. The Authorized Officer is hereby authorized, subject to the approval of the Corporation Counsel, to negotiate any and all terms and provisions in connection with the Grant which do not substantially modify the terms described in Exhibit A hereto. Upon the execution and receipt of proper documentation, the Authorized Officer is hereby authorized to disburse the proceeds of the Grant to the Grantee. SECTION 3. NOF proceeds in the amount set forth in Exhibit A are hereby appropriated for the purposes described herein. SECTION 4. To the extent that any ordinance, resolution, rule, order or provision of the Code, or part thereof, is in conflict with the provisions of this ordinance, the provisions of this ordinance shall control. If any section, paragraph, clause or provision of this ordinance shall be held invalid, the invalidity of such section, paragraph, clause or provision shall not affect any other provisions of this ordinance. SECTION 5. This ordinance shall be in full force and effect from and after the date of its passage and approval. i. Exhibit A Attached llliil 8 i] !aH 11a — QSSSSS333BE&11 NOF CONDITIONAL AWARD LETTER March 7, 2019 Jeff Head Ogden Washtenaw JV LLC 350 West Hubbard Street Chicago, Illinois 60654 Dear Mr. Head, Congratulations, your application for Mayor Emanuel's Neighborhood Opportunity Fund ("NOF") has been conditionally approved for up to $2,500,000 in NOF Grant assistance, subject to City Council approval and execution of a Redevelopment Agreement ("RDA") with the City of Chicago (the "City"), through the Department of Planning and Development ("DPD"). This letter outlines the general terms and conditions ofthe approval. Your application was selected and approved based on its proposed Project Plan and Project Scope, which are described below. If any changes are made to either the Project Plan or Project Scope, you must inform DPD in advance of proceeding. Any changes without DPD's prior written approval may result in forfeiture ofthe NOF Grant. Property Address: 2632 West Ogden Avenue, Chicago, Illinois 60608 (PIN 16-24-213-012-0000) 2638 West Ogden Avenue, Chicago, Illinois 60608 (PIN 16-24-213-011-0000) 2646 West Ogden Avenue, Chicago, Illinois 60608 (PIN 16-24-213-010-0000) Project Plan and Project Scope: The Project represents phase one of a multi-phase redevelopment program designed to bring new economic development and housing to the North Lawndale Community. Phase I will include approximately 52,000 square feet of office and retail space. The NOF grant will be utilized towards the core and shell and tenant improvements associated with retail tenants, who include Steak & Shake, Ja'Grill and a third retail tenant, yet to be identified. The office space tenants will be Mt. Sinai Hospital and Cinespace Studios. Estimated Project Costs: Project Sources and Uses Table Anticipated Project Costs Anticipated Sources of Funds Hard Costs $17,765,655 Equity $912,566 Soft Costs $3,372,571 Debt $10,400,000 Acquisition Costs $600,000 NOF Grant $2,500,000 Other Costs $0 Qualified Opportunity Zone $7,925,660 Total $21,738,226 Total $21,738,226 Payment of NOF Grant: The NOF Grant will be reimbursed to the Grantee following the completion of the project and the issuance of a Certificate of Completion by DPD. NOF Covenants: Operations and Occupancy Covenants. The Grantee shall continuously own, occupy, and operate the entirety ofthe Project for three years following the issuance of the Certificate of Completion. Ifthe Grantee fails to satisfy these requirements, the City shall have the right to cease NOF payments or terminate the RDA. The City may also have the right to place a lien on the subject property. Annual Compliance Report. The Grantee shall be required to provide an Annual Compliance Report. The compliance monitoring period will extend at least 3 years from the issuance of the Certificate of Completion for the Project. Requirements for the Annual Compliance Reports will be detailed in the RDA. NOF Grant Award Conditions: Disbursement of the NOF Grant funds is subject to the following conditions, which will be further detailed in the RDA. Closing. Prior to closing, the Grantee must satisfy certain conditions before the City will execute and deliver the RDA, unless such conditions are waived in writing by the City. Grantee shall close on the RDA within 90 days of Council authorization. Certificate of Completion. Grantees are to complete construction expeditiously following the execution of the RDA. A Certificate of Completion must be issued prior to the second anniversary of the issuance of this NOF Conditional Award Letter, or the Project will be considered in default and the NOF Grant may be forfeited and the RDA may be terminated. Project Budget. Increases to project costs will be your sole responsibility and will not necessitate an increase in the approved NOF Grant amount. Project Financing. Proof of project financing, evidencing that all available sources of funds outside of the NOF Grant amount are secured and available, must be submitted to DPD by February 19, 2019. Documentation. All eligible project costs must be appropriately documented. Documentation includes, but is not limited to, detailed invoices, cancelled checks, sworn owner's statement, sworn statement of contractor and subcontractor to owner and final lien waivers. Permits. All permits which are required by the City's Municipal Code must be obtained in order for that work and its corresponding costs to be considered eligible for NOF assistance. Business Licenses. All necessary business licenses must be obtained by the business prior to the NOF Grant being fully disbursed. MBE/WBE Requirements. The Grantee must meet at least 26% MBE/ 6%WBE participation for the Project's direct and indirect costs of construction. Prior to the closing date, the Grantee, general contractor and all major subcontractors shall be required to meet with the monitoring staff of DPD with regard to the Grantee's plan to achieve its obligations as established in the RDA and as mandated by City Council ordinance and DPD policy. 9. City Residency/Prevailing Wage Requirements. City residents must perform 50% of al! construction hours. Grantee is subject to the City's prevailing wage requirement for all construction trades, as established by the Illinois Department of Labor. Permitted Uses. The Grantee understands that the permitted uses of property and improvements are only as allowed by the Redevelopment Agreement and the applicable zoning restrictions. Limitations on Other City Funds. NOF funds may not be combined with other City funds, including but not limited to a TIF redevelopment agreement, the Small Business Improvement Fund or the Adopt-a-Landmark Fund. 12. Build Community Wealth Bonus. The amount ofthe Build Community Wealth Bonus is capped at 15% of your total eligible project costs for the support of locally-based business and property owners or for creating employment opportunities in areas in need of new jobs. Once more, we wish to extend congratulations to you for being selected for Mayor Emanuel's NOF program. We look forward to supporting you in your efforts to revitalize our City's neighborhoods. Any questions regarding the NOF requirements and procedures can be addressed to Robert Bumpers at (312) 744-0107, Robert.Bumpers@cityofcliicBKO.org
Sincerely,
David Reifman Commissioner
Department of Planning and Development
Date
On behalf of Ogden Washtenaw JV LLC ("Grantee"), we accept the above terms and conditions ofthe NOF
Grant offered by the City of Chicago. \, f
Jeff Head
City of Chicago
Department of Planning and Development Attention: Robert Bumpers 121 North LaSalle Street, RM 1006 Chicago, IL 60602
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
Legal name of the Disclosing Party submitting this EDS. Include d^/a/ if applicable: OGDEN COMMONS JV LLC
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[^] the Applicant
OR
j^j a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: ogden washtenaw jv llc __
3. a legal entity with a direct or indirect right of control ofthe Applicant (see1 Section 11(B)(1))
State thelegal name of the entity in which the Disclosing Party holds a right of control:
Business address ofthe Disclosing Party: 350 west hubbard street suite soo
CHICAGO, IL 60654
Telephone: 012)527-5400 Fax: (312)527-7440 Email: jheadi@habiiat.com
Name of contact person: Jeff Head
Federal Employer Identification No. (if you have one), _ _
Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Applicant is seeking Neighborhood Opportunity Zono Kinds to assist with the development of a mixed use project at West Ogden Ave. and Washtenaw Ave . Chicago
Which City agency or department is requesting this EDS? Department of Planning & Development
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification tf N/A and Contract// .
Ver.2018-1 Page 1 of] 5
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Partyj_ 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 the not-for-profit corporation also a 501(c)(3))? No
Yes
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
DELAWARE
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 [ [Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
HABITAT OGDEN COMMONS LLC Managing Member
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
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limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Habitat Ogden Commons LLC 350 W. Hubbard St., Ste. 500, Chicago, IL 60654 50%
Ogden Commons MSH LLC 1500 S. California Ave., Chicago, IL 60608 20%
Lawndale Ogden Development LLC 2621 W. 15th Place, Chicago, IL 60608 30%
SECTION III -- INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? QYes [^/]No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month period following the date of this EDS? Yes [^jNo
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosing Party? Q]Yes g]No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(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 (as defined in MCC Chapter 2-156), 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. Ifthe 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 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)
y/ 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 MCC 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?
QYes [/] No QNo 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?
QYes [/]No
FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to. water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
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The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(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, during the 5 years before 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 subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before 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 Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:
the Disclosing Party;...
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
, • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
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Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any 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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] ofthe Applicant 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 of 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 MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant 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 Certifications (2) and (9) above and will not, without the prior written consent ofthe City, use any such
Ver 2018-1 Page 6 of 15
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. . If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
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.
12. 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 date of this EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").
None
13. 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, 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 $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
None
C. CERTIFICATION OF "STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ [is [7] is not
a "financial institution" as defined in MCC Section 2-32-455(b).
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 MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. 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."
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Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
N/A
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 FINANCIAL INTEREST IN,CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
1. In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge after reasonable inquiry, 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
?
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), skip Items D(2) and D(3) and 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 0No
If you checked "Yes" ta.Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature ofthe financial interest:
Name Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
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E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. Ifthe Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
Iv^l 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, 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 ifthe 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, as amended, have made lobbying contacts on behalf ofthe 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
Ver.2018-1 Page 9 of 15
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.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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?
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.)
2. 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?
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 of 15
- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance 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 this ordinance.
Ifthe 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 City transactions. 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 in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. Ifthe 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 MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1 -23 and Section 2-154-020.
Page II of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate and complete as ofthe datefurnished to the City.
(see opposite)
(Print or type exact legal name of Disclosing Party)
By:___
(Sign here)
OGDEN COMMONS JV LLC
By: Habitat Ogden Commons LLC, its Managing Member By: Habitat Acquisitions Company LLC, its Manager
By: The Habitat Company LLC, its Manager
By:
Name: Matthew G. Fiascone Its: President
(Print or type title of person signing)
-2.
Signed and sworn to before'me on (date) L5 - J> - / 9
at Cook | bounty, lllinois (state).
Or-FOAL SEAL M DRWIEGA no " ary PUBLIC ¦ STATE OF ILUNOIS m COMMISSION EXPIRES:07/30/19
Notary Pupli Commission expires
PaRe 12 ot" 15
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%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC 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 cily 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 TLB. 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 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% 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 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 15
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% (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 MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
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 MCC Section
2-92-416?
J The Applicant is not publicly traded on any exchange.
3. If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which
the pertinent code violations apply.
Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.amleual.com ), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the Cily money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
[y^|N/A -1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385.
This certification shall serve as the affidavit required by MCC Section 2-92-3 85(c)(1),
If you checked "no" to the above, please explain.
Page 15 of 15
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: OGDEN WASHTENAW JV LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
[7j the Applicant
OR
QJ a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR
[_J a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
B. Business address ofthe Disclosing Party: 350 west hubbard street suite soo
CHICAGO, IL 60654
Telephone: (312)527-5400 Fax: (312)527-7440 Email: jhcadi@habitat.com
Name of contact person: Jeff Head
Federal Employer Identification No. (if you have one):
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Applicant is seeking Neighborhood Opportunity Zone funds lo assist with the development of a mixed use project ot West Ogden Ave and Washtenaw Ave . Chicago
G. Which City agency or department is requesting this EDS? Department of Planning & Development
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification U N/A _ and Contract //
Ver 20IS-1 Page I of 15
- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
z
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
Indicate the nature of the Disclosing Party
Limited liability company Limited liability partnership Joint venture
rrs-
Not-for-profit corporation the not-for-profit corporation also a 501(c)(3))? No
Yes
[ ] Other (please specify)
For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
DELAWARE
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?
[2 Yes [Q Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Ogden Commons JV LLC
Title
Managing Member
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
1'nge 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Ogden Commons JV LLC 350 W Hubbard St Ste 500 Chicago, IL 60654 100%
SECTION III -- INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? Q|Yes [j/]No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? Q] Yes / No
If "yes" to either ofthe above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
No
?
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have, a financial interest (as defined in Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party?
Yes /
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(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 (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects lo 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. 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 15
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.
SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF
(Add sheets if necessary)
iQ] 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 MCC 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 [/j^0 I |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?
QYes QNo
FURTHER CERTIFICATIONS,
[This paragraph 1 applies only ifthe Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of 15
3. The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(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, during the 5 years before 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 subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before 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 Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) 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 ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 15
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 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC.Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any 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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] ofthe Applicant 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 MCC Chapter 1-23, Article. I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant 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 Certifications (2) and (9) 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 Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. Ifthe Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. 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 date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
None
13. 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 $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
None
is
?
/
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION 1. The Disclosing Party certifies that the Disclosing Party (check one)
is not
a "financial institution" as defined in MCC Section 2-32-455(b). 2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
/
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. 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."
Page 7 of 15
Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
N/A
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
| | Yes
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), skip Items D(2) and D(3) and proceed to Part E.
2. 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 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?
QYes |/1 No
3. If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
Page 8 of 15
11 CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. Ifthe Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
h7] 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
I I 2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf ofthe Disclosing Party with respect to the Matter: (Add sheets if necessary):
N/A
(If no explanation appears .or begins on the lines above,: or if the letters "NA" or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Parly means that NO persons or entities registered under the Lobbying Disclosure Act of 1995, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds lo pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or 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 ol" Congress, or an employee
Ver 2018-1 Page 9 of 15
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.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require 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?
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
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?
/ Yes
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 of 15
- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance 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 this ordinance.
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 City transactions. 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 in, and appended to, this EDS may be made publicly available 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. f
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 MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
Page 11 of 15
CERTIFICATION
(see opposite)
(Print or type exact legal name of Disclosing Party)
By: ]
(Sign here)
(Print or type name of person signing)
OGDEN WASHTENAW JV LLC
By: Ogden Commons JV LLV, its Managing Member
By: Habitat Ogden Commons LLC, its Managing Member By: Habitat Acquisitions Company LLC, its Manager By: The Habitat Company LLC, its Manager
... Or
By:
Name: Matthew G. Fiascone Its: President
(Print or type title of person signing)
Signed and sworn to before me on (date)
at
Cook
H
Notary Public! Commission expires:
OFFICIAL SEAL M DRWIEGA NOTARY PUBLIC • STATE OF ILLINOIS MVCOMMISSION EXPIRES 07/30/19
Page 12 o(15
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%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC 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., ifthe 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 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% 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?
QYes [/iNo
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] 5
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAYWPROBLEM 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% (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 MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
2. Ifthe 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 MCC Section 2-92-416?
3. If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.am legal .com), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services,.work or goods provided (including for legal or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
QYes
?No
?N/A -1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l). If you checked "no" to the above, please explain.
Page 15 of 15
EXHIBIT "Ar
City of Chicago Economic Disclosure and Affidavit Ogden Washtenaw JV LLC SECTION IV: DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
Name (indicate whether retained or anticipated to be retained) Business Address Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.) Fees (indicate whether paid or estimated)
App legate & Thorne-Thomsen (retained) 425 S Financial Place Suite 1900 Chicago, IL 60605 Attorney $100,000 (estimated)
(3)
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: HABITAT OGDEN COMMONS LLC
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
| | the Applicant
OR
[/j a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: ogden washtenaw jv llc ___
?] a legal entity with a direct or indirect right of control ofthe Applicant (see Section 11(B)(1)) State the legal name ofthe entity in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 350 west hubbard street suite soo
CHICAGO. IL 60654
Telephone: (312)527-5400 Fax: 012)527-7440 Email: jheadi ©habitat com
Name of contact person: Jeff Head
Federal Employer Identification No. (if you have one):
Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Applicant is seeking Neighborhood Opportunity Zone funds to assist with '.he development of a mixed uso project at West Ogden Ave and Washtenaw Ave , Chicago
G. Which City agency or department is requesting this EDS? Department of Planning & Development
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
•Specification H _ and Contract //
Ver.20 IS-1 Paget of 15
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature ofthe 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
Doration also a 501(c)(3))? No
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
ILLINOIS
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 £ Organized in Illinois
B. IF I HE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
Habitat Acquisitions Company LLC Manager
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest, of a member or manager in a
Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Habitat Acquisitions Company LLC 350 West Hubbard St., Ste 500, Chicago, IL 60654 45%
SECTION III -- INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? QjYes /
No
No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month period following the date of this EDS? Yes /
If "yes" to either ofthe above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosing Party?
QYes [/jNo
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(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 (as defined in MCC Chapter 2-156), 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. 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 15
Name (indicate whether Business retained or anticipated Atldress to be retained)
Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
/ Check here ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V- CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC 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?
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 [7]No
B. FURTHER CERTIFICATIONS
[This paragraph 1 applies only ifthe Matter'is a contract being handled by the City's Department of Procurement Services.J In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered hy the Illinois Department of Revenue.
Page 4 of 15
The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) of this HDS:
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, during the 5 years before 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 ofthe offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before 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 Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) 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 ofthe Disclosing Party, any Contractor or any Affiliated Entity or any-other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5uf 15
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 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted lo bribe, or been convicted or adjudged guilty of bribery or attempting lo 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 lo 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarrhent Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or ofthe United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] ofthe Applicant 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 with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will nol use, nor permit their subcontractors lo use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant 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 Certifications (2) and (9) above and will not, without the prior written consent ofthe City, use any such
Vcr.2018-1 , Page 6 of 15
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. Ifthe Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
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 lo the above statements.
12. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the date of this EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").
None
13. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
None
is
?
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION 1. The Disclosing Party certifies that the Disclosing Party (check one)
is not
a "financial institution" as defined in MCC Section 2-32-455(b).
2. Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will nol become a predatoiy lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. 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."
Page 7 of 15
Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
N/A
Ifthe letters "NA," the word "None." or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
1. In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge after reasonable inquiry, does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
/ No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
2. 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 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?
/ No
3. If you checked "Yes" to Item D(l), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature of the financial interest:
Nature of Financial 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. Ifthe Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
_ 1The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued lo slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Q
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: Ifthe 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, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
N/A
(If no explanation appears or begins on the lines above, or ifthe 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, as amended, 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
Ver.201 S-1 Paw: 9 of 15
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.
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 cither: (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 1986 but has nol engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
Ifthe Disclosing Parly is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNI TY
Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing al the outset of
negotiations.
Yes / No
Is the Disclosing Party the Applicant?
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.)
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?
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
If you checked "No" to question (I) or (2) above, please provide an explanation:
P.iee 10 ot" 15
SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
'I he City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.cityofchicafto.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 this ordinance.
Ifthe 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 lo allow the Disclosing Party to participate in other City transactions. 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 in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article 1 (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1 -23 and Section 2-154-020.
Paue 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and all applicable Appendices, arc true, accurate and complete as ofthe date furnished to the City.
(see opposite) HABITAT OGDEN COMMONS LLC
(Print or type exact legal name of Disclosing Party)
By: Habitat Acquisitions Company LLC, its Manager
By: The Habitat Company LLC, its Manager
Name: Matthew G. Fiascone Its: President
Notary Public
Hiige 12 of 15
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%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Parly 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 RDS 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 ofthe following, whether by blood or adoption: parent, child, brother or sister, aunl 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 TLB. 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 of the Disclosing Party; and (3) any person having more than a 7.5% 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?
If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFI LAW/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% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
QYes ON0
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 MCC Section 2-92-416?
J^Yes [ZH^0 I [The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.amlcaal.com ), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
| |Yes
QNo
| |N/A - I am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l). If you checked "no" to the above, please explain.
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(4)
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: HABITAT ACQUISITIONS COMPANY LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is: 1. Qj] the Applicant OR
2: [/J a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal name: ogden washtenaw jv llc
~OR~
State the
3. ? a legal entity with a direct or indirect right of control ofthe Applicant (see Section 11(B)(1))
egal name ofthe entity in which the Disclosing Party holds a right of control:
B. Business address ofthe Disclosing Party: 350 west hubbard street suite sop
CHICAGO. IL 60654
Telephone: 012)527-5400 j?ax: 012) 527-7440 Email: jheadi@habiiat.com
Name of contact person: Jeff Head
Federal Employer Identification No. (if you have one).
F. Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Applicant is seeking Neighborhood Opportunity Zone funds to assist with the development of a mixed use project at West Ogden Ave. and Washtenaw Ave Chicago
G. Which City agency or department is requesting this EDS? Department of Planning & Development
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # __ _ and Contract if _
Vcr.20 I S-l Pago 1 of 15
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature ofthe Disclosing Parlv: 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
wation also a 501(c)(3))? No
y)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
ILLINOIS
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?
?jYes L—^0 / Organized in Illinois
J3. IF THE DISCLOSING PAR'IY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
The Habitat Company LLC Manager
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
The Habitat Company LLC 350 W. Hubbard St, Ste. 500, Chicago, IL 60654 45%
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? i^jYes /No
No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month period following the date of this EDS? QjYes /
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosing Party? QYes |/]No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(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 (as defined in MCC Chapter 2-156), 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. Ifthe 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 15
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)
y/ 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 MCC 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?
QYes [/]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?
QYes [7]
B. FURTHER CERTIFICATIONS
1. [This paragraph I applies only ifthe Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
.2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee. tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of 15
The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section 1.1(B)(1) of this KDS:
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, during the 5 years before 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 subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before 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 Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) 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 ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Ver 2018-1 ¦ Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity ol'either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 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 adjuciged 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarmcnt Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any 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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] ofthe Applicant 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 with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
| FOR APPLICANT ONLY] T he Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant 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 Certifications (2) and(9) 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 Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. I f the Disclosing Party is unable to certi fy to any of the above statements in this Part B (Further' Certifications), the Disclosing Party must explain below:
N/A
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. 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 date of this EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").
None
13. 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 $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
None
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
| | is / is not
a "financial institution" as defined in MCC Section 2-32-455(b).
Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. 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."
Ver 2018-1 Pa_.e7ol'I5
Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
N/A
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
1. In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge after reasonable inquiry, 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?
QYes
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), skip Items D(2) and D(3) and proceed to Part E.
2. 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?
QYes [/]No
3. If you checked "Yes" to Item D(l), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature ofthe financial interest:
Name Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
I'age 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. Ifthe Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
y_J_l. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
N/A
(If no explanation appears or begins on the lines above, or ifthe letters "NA" or ifthe 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. as amended, 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 or employee of any agency, as defined
by applicable federal law. a member of Congress, an officer or employee of Congress, or an employee
Vcr.20!8-! I'agc 9 of 15
ol' 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.
The Disclosing Party will submit an updated certification al 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.
T he 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(e)(4) of ihe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.
B. CERT IFICATION REGARDING EQUAL EMPLOYMENT' OPPORTUNI TY
Ifthe 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?
QYes j/]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.)
QYes | | No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ [ Yes L_^° QjReports not required
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
QYes QNo
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 oi' 15
SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Parly understands and agrees thai:
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. T he Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.cityofchicaao.org/Eth ics, 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 this ordinance.
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 City transactions. 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 in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
Pas.;e 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this HDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this HDS, and all applicable Appendices, are true, accurate and complete as ofthe date furnished to the City.
(see opposite) ' HABITAT ACQUISITIONS COMPANY LLC
(Print or type exact legal name of Disclosing Party)
(Print or type title of person signing)
By: The Habitat Company LLC, its Manager
OFFICIAL SEAL LORIFCHACOS
NOTARY PUBLIC • STATE OF ILLINOIS MY COMMISSION EXPIRES:01/23/21
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%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC 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 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 the Disclosing Party listed in Section II.B. 1 .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, ifthe Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% 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?
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.
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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% (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 MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
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 MCC Section
2-92-416?
The Applicant is not publicly traded on any exchange.
3. If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
i
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.amlegal.com ), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
QYes
QNo
| |N/A -1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l). If you checked "no" to the above, please explain.
I'at'.e J5 ol' 15
(5)
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:
THE HABITAT COMPANY LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
Q] the Applicant '
OR
|2 a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal name: ogden washtenaw jv llc
OR """
r~J a legal entity with a direct or indirect right of control ofthe Applicant (sec Section 11(B)(1)) State the legal name ofthe entity in which the Disclosing Party holds a right of control:
B. Business address ofthe Disclosing Party: 350 w. hubbard st ste soo
CHICAGO. IL 60654
Telephone: (312)527-5400 _ _ Fax: (3i2)994-783a Email: JtHEADi@HABiTAT.coM
Name of contact person: .J_^F2!___ '
Federal Employer Identification No. (if you have one):
Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Applicant ,s seeking Nekj^ncrhocd Gpconjniiy Zo^e funds to assist with the development of ;i rr xed -se pr:;;ect al West Ogden A'.-} ;}nd Wcs^.e'iov,- Ar.*, Chcsco
G. Which City agency or department is requesting this EDS? Department of Planning & Development _
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification ?/ N/A and Contract if
Ver.2018-1 ^. Page I of IS
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 Limited partnership Trust
Limited liability company Limited liability partnership Joint venture
Not-for-profit corporation
Yes
' (please speedy)
Duration also a 501(c)(3))? No
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
ILLINOIS
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?
J Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which arc legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Daniel E Levin .150 West Hubbard St., Ste. 500, Chicago, IL 60654
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? QjYes J No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? | | Yes J No
If "yes" to either ofthe above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
No
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosing Party?
QYes [7
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partncr(s) and describe the financial interest(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 (as defined in MCC Chapter 2-156), 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 of the fees paid or estimated to be paid. Tho Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll. Ifthe 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.
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Name (indicate whether Business Relationship to Disclosing Party Pees (indi^ue whether
retained or anticipated Address (subcontractor, attorney, lUy^iyr.VJiLiDy^d-) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
SEE ATTACHED FXHIBIT "B"
(Add sheets if necessary)
?[Check here ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECT ION V -- CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC 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?
j | Yes J 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 [7
B. FURTHER CERTIFICATIONS
[This paragraph 1 applies only ifthe Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) helow] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
T he Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to. water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 ol' 15
The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) of this EDS:
are not presently debarred, suspended, proposed lor debarment, declared ineligible or voluntarily excluded from any transactions by any federal, slate or local unit of government;
have not, during the 5 years before 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 subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before 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 Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) 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 (hat directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant lo the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 15
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 5 years before the date of this HDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local cfovemment 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 Ihe offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant 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 with Article I is a continuing requirement for doing business with the Cily. NOTE: If MCC Chapter 1-23, Article 1 applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use. any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY) T he Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equai in form and substance to those in Certifications (2) and (9) 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 Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. Ifthe Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
Ifthe letters "NA." the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Parly certified to the above statements.
12. 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 date of this EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").
None
13. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does 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 $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
None
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITU TION
/
The Disclosing Parly certifies that the Disclosing Party (check one)
is not
a "financial institution" as defined in MCC Section 2-32-455(b).
2. Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We arc not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. 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."
Page 7 of 15
Ifthe Disclosing Party is unable lo make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
N/A
Ifthe letters "NA," ihe word "None," or no response appears on the lines above, il will be conclusively presumed that the Disclosing Party certified to the above statements.
D: CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
1. In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge after reasonable inquiry, docs any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
QYes [/
NOTE: If you checked "Yes" to Item D(l), proceed lo Hems D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
2. 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 [/]No
3. If you checked "Yes" to Item D(l), provide the names and business addresses of the City officials or employees having such financial interest and identify the nature ofthe financial interest:
Name Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
P;ige8o!"15
CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check cither (I) or (2) below. Ifthe Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure lo comply with these disclosure requirements may make any contract entered into with the City in connection wilh the Matter voidable by the City.
1^1 1. T he Disclosing Party verifies that the 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 or injury or death of their slaves), and the Disclosing Party has found no such records.
I | 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 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: Ifthe Matter is federally funded, complete this Section VI. Ifthe 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 nol federal funding.
A. CERTIFICAT ION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
N/A
(If no explanation appears or begins on the lines above, or ifthe letters "NA" or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Parly means that NO persons or entities registered under ihe Lobbying Disclosure Act of 1995, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)
2. T he Disclosing Party has not spent and will not expend any federally appropriated hinds 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
Ver 2018-1 Page 9 of 15
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.
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) ofthe Internal Revenue, Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNIT Y
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?
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.)
2. 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?
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
11 you checked "No" to question (1) or (2) above, please provide an explanation:
Prnze 10 of 15
SECTION VII _ FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this LDS 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 Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.cilyol'chicago.t)rg/lahics , 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 this ordinance.
Ifthe City determines that any information provided in this F,DS 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 City transactions. 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 in, and appended to, this EDS may be made publicly available 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 verily the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject lo MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
Piige 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate and complete as ofthe date furnished to the City.
THE HABITAT COMPANY LLC
(Print or type exact legal name of Disclosing Party)
(Sign here)
MATTHEW G FIASCONE
(Print or type name of person signing)
PRESIDENT
(Print or type title of person signing)
Notary Public
Signed and sworn lo before me on (date) \^l
Gf-HCIAL SEAL LORI FCHACOS NOTARY PUBLIC - STATE OF ILUNOIS MY COMMISSION EXPIRES:01/23/21
Page 12 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to he completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC 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 F,DS 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 ofthe following, whether by blood or adoption: parent, child, brother or sister,.aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mothcr-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers ofthe Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, ifthe 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% 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?
If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 15
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% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scoffiaw or problem landlord pursuant to MCC Section 2:92-416?
QYes QNo
IIThe 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 MCC Section 2-92-416?
?I Yes LZ]No j [The Applicant is not publicly traded on any exchange.
3. If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERT IFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.amlogal.comL generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants1 wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l).
If you checked "no" to the above, please explain.
Page IS of 15
EXHIBIT "A"
City of Chicago Economic Disclosure and Affidavit The Habitat Company LLC SECTION II: DISCLOSURE OF OWNERSHIP INTERESTS
B. l(i) all executive officers and all directors ofthe entity
B. 1 (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.
DANIEL E. LEVIN, CHAIRMAN / MANAGER
MATTHEW G. FIASCONE PRESIDENT / MANAGER
STEPHEN F. GALLER EXECUTIVE VICE PRESIDENT / GENERAL COUNSEL / MANAGER
SHEILA BYRNE EXECUTIVE VrCE PRESIDENT / PROPERTY MANAGEMENT / MANAGER
THOMAS BLACK SENIOR VICE PRESIDENT, ARCHITECT & DIRECTOR OF PROJECT MANAGEMENT
MICHAEL CARSON SENIOR VICE PRESIDENT / CHIEF INFORMATION OFFICER
CYNTHIA DIETZ SENIOR VICE PRESIDENT / CORPORATE CONTROLLER
CHARLTON HAMER SENIOR VICE PRESIDENT / PUBLIC HOUSING PORTFOLIO
BRYAN SULLIVAN SENIOR VICE PRESIDENT / ACQUISITIONS & INVESTMENTS
LORI CHACOS VICE PRESIDENT / ASSISTANT GENERAL COUNSEL
SHYRLDEN CARMICHAEL VICE PRESIDENT / BUSINESS OPERATIONS
JEFFREY D. HEAD VICE PRESIDENT / COMMUNITY DEVELOPMENT GROUP
LORI FLASKA VICE PRESIDENT / HUMAN RESOURCES
GIN A FORTUNE-HARMON VICE PRESIDENT / MARKET RATE
MAUREEN VAUGHN VICE PRESIDENT / MARKETING & COMMUNICATIONS
HAGOP (JACK) DEVEDJIAN VICE PRESIDENT / FACILIT IES MANAGEMENT AND ENGINEERING
CHRISTINE FRIEND VICE PRESIDENT / CONDOMINIUM MANAGEMENT
EXHIBIT "B"
City of Chicago Economic Disclosure and Affidavit The Habitat Company LLC SECTION IV: DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
Name (indicate whether retained or anticipated to be retained) Business Address Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.) Fees (indicate whether paid or estimated)
RubinBrown LLP (anticipated to be retained) 4709 W. Golf Rd. Skokie, IL 60076 Accountant $25,000 (estimated)
IRR Chicago (retained) 400 E. Randolph St. Chicago, IL 60601 Appraisal $20,000 (estimated)
Solomon Cordwell Buenz (retained) 625 N. Michigan Ave. Chicago IL 60601 Architect $725,000 (estimated)
Chico & Nunes (retained) 333 W. Wacker Dr., Ste. 1420 Chicago, IL 60606 Attorney $100,000 (estimated) $10,000 (paid)
DLA Piper (retained) 444 W. Lake St. Chicago, IL 60606 Attorney $100,000 (paid)
Neal and Leroy, LLC (retained) 120 N. LaSalle, Ste. 2600 Chicago, IL 60602 Attorney $125,000 (estimated) $110,000 (paid)
Baker Tilly (retained) 205 N. Michigan Ave. Chicago, IL 60601 Market Study $10,000 (paid)
TERRA Engineering Ltd. 1 (retained) 225 W. Ohio St., 4lh Floor Chicago, 1L 60654 Survey, Civil Engineering $50,000 (estimated)
Sam Schwartz Engineering (retained) 303 W. Eric St. Chicago, IL 60654 Traffic Study $ 10,000 (estimated)
CohnReznick (retained) 500 E. Pratt St., 4,h Floor Baltimore, MD 21202 Accountant $25,000 (estimated)
James McHugh Construction Co. (anticipated to be retained) 1737 S. Michigan Ave. Chicago, IL 60616 General Contractor $14,000,000 (estimated)
McLaurin Development Partners (anticipated to be retained) 120 N. Racine Ave., 2nd FL Chicago, IL 60607 Retail Leasing Brokerage $300,000 (estimated)
Carnow, Conibear & Assoc., Ltd. (retained) 600 W. Van Buren St., Ste. 500 Chicago, IL 60607 Environmental $50,000 (estimated) $21,260 (paid)
Terracon Consultants Inc. (retained) 650 W. Lake St, Ste. 420 Chicago, IL 60661 Environmental $55,000.00 (estimated) $35,884.80 (paid)
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: OGDEN COMMONS MSH LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Pirty submitting this EDS is:
1. | | the Applicant
OR
2. a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other i ndertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: ogden washtenaw jv llc
or indirect right of control of the Applicant (see Section 11(B)(1)) which the Disclosing Party holds a right of control:
B. Business address of the Disclo
Chicago, IL 60608
C. Telephone: (773)257-5011
D. Name Of Contact person: Jesse l. Green
n No. (if you have one):
to which this EDS pertains. (Include project number and location of
Applicant is seeking Neighborhood Opportunity Zone fun Js to assist with the development of a mixed use project at West Ogden Ave. and Washtenaw Ave., Chicago
G. Which City agency or/departm :nt is requesting this EDS? Department of Planning & Development
handled by the City's Department of Procurement Services, please
and Contract #
If the Matter is a contract being complete the following:
Page I of 15
Specification # •__
Ver.2018-1
SECTION II -
- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
company partnership
Limited liability Limited liability Joint venture
Yes
Not-for-profit corporation the not-for-profii corporation also a 501(c)(3))?
[ ] Other (please specify)
[jNo
2. For legal entities, the state (or foreign country) of incorporation o|r organization, if applicable:
ILLINOIS
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?
J Organized in Illi
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
officers and all directors of which are legal entities (if there 'iii) for trusts, estates or other
party; (iv) for general or partnerships or joint ventures, or legal entity that directly or
1. List below the full names and titles, if applicable, of: (i) all executive the entity; (ii) for not-for-profit corporations, all members, if any, are no such members, write "no members which are legal entities"); similar entities, the trustee, executor, administrator, or similarly situated limited partnerships, limited liability companies, limited liability each general partner, managing member, manager or any other person indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its ow
Name
Loren Chandler
Title
Manager/President/Treasure
Vice President/Secretary
Vice President
or legal entity having a direct or ) beneficial interest (including interest include shares in a
of a member or manager in a
2, Please provide the following information concerning each person indirect, current or prospective (i.e. within 6 months after City actior ownership) in excess of 7.5% of the Applicant. Examples of such ar corporation, partnership interest in a partnership or joint venture, interest
Page 2 of 15
limited liability company, or inte state "None." NOTE: Each legal entity listed b Name Busine Mount Sinai Hospital Medical Center of Chica est of a beneficiary of a trust, estate or other similar entity. If none, slow may be required to submit an EDS on its own behalf. ;s Address Percentage Interest in the Applicant o 1500 S. California Ave., Chicago, IL 60608 20%
SECTION III -- INCOME OR OFFICIALS Has the Disclosing Party provide 12-month period preceding the d< Does the Disclosing Party reason elected official during the 12-moi If "yes" to either of the above, pie describe such income or compens COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED 1 any income or compensation to any City elected official during the te of this EDS? ? Yes / No ibly expect to provide any income or compensation to any City ith period following the date of this EDS? ? Yes / No ase identify below the name(s) of such City elected official(s) and ation:
Does any City elected official or, inquiry, any City elected official' Chapter 2-156 of the Municipal ( QYes £]N If "yes," please identify below th( partner(s) and describe the financ to the best of the Disclosing Party's knowledge after reasonable ; spouse or domestic partner, have a financial interest (as defined in lode of Chicago ("MCC")) in the Disclosing Party? ; name(s) of such City elected official(s) and/or spouse(s)/domestic ial interest(s).
SECTION TV -- DISCLOSURE The Disclosing Party must disclo lobbyist (as defined in MCC Cha whom the Disclosing Party has re the nature of the relationship, and Disclosing Party is not required t< Party's regular payroll. If the Dis Section, the Disclosing Party mus disclosure. Vcr.2018-1 OF SUBCONTRACTORS AND OTHER RETAINED PARTIES >e the name and business.address of each subcontractor, attorney, 3ter 2-156), accountant, consultant and any other person or entity tained or expects to retain in connection with the Matter, as well as the total amount of the fees paid or estimated to be paid. The ) disclose employees who are paid solely through the Disclosing closing Party is uncertain whether a disclosure is required under this t either ask the City whether disclosure is required or make the Page 3 of 15
Name (indicate whether Business retained or anticipated Address to be retained)
NONE
Relationship to Disclosing Paity (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NOTE: "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 tty retain, any such persons or entities. SECTION V -- CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC 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 co upetent 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?
QYes | |No
halndled by the City's Department of s EDS, neither the Disclosing led, in connection with the monitor, independent private sector or entity with legal, auditing, help the agency monitor the
their business practices so they a contract in progress).
B. FURTHER-CERTIFICATIONS
th
d lal
to foim
1. [This paragraph 1 applies only if the Matter is a contract being Procurement Services.] In the 5-year period preceding the date of Party nor any Affiliated Entity [see definition in (5) below] has enga performance of any public contract, the services of an integrity inspector general, or integrity compliance consultant (i.e., an indivi investigative, or other similar skills, designated by a public agency activity of specified agency vendors as well as help the vendors re can be considered for agency contracts in the future, or continue wit!
in the payment of any fine, fee, including, but not limited to, water sjiles taxes, nor is the Disclosing s Department of Revenue.
2. The Disclosing Party.and its Affiliated Entities are not delinquen; tax or other source of indebtedness owed to the City of Chicago, and sewer charges, license fees, parking tickets, property taxes and Party delinquent in the payment of any tax administered by the lllindi
Page 4,of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) of this EDS:
a. are not presently debarred, suj excluded from any transactions b
pended, proposed for debarment, declared ineligible or voluntarily any federal, state or local unit of government;
b. have not, during the 5 years before adjudged guilty, or had a civil judg attempting to obtain, or performir public transaction; a violation of bribery; falsification or destructioh
the date of this EDS, been convicted of a criminal offense, ment rendered against them in connection with: obtaining, g a public (federal, state or local) transaction or contract under a federal or state antitrust statutes; fraud; embezzlement; theft; forgery; of records; making false statements; or receiving stolen property;
c. are not presently indicted for, state or local) with committing an
>r criminally or civilly charged by, a governmental entity (federal, y of the offenses set forth in subparagraph (b) above;
d. have not, during the 5 years bejfore (federal, state or local) terminated
the date of this EDS, had one or more public transactions for cause or default; and
any i
e. have not, during the 5 years liable in a civil proceeding, or in environmental violations, institutejd unit of local government.
bejfore the date of this EDS, been convicted, adjudged guilty, or found criminal or civil action, including actions concerning by the City or by the federal government, any state, or any other
4. The Disclosing Party understands Chapters 2-56 (Inspector General)
and shall comply with the applicable requirements of MCC and 2-156 (Governmental Ethics).
any <
contractor or subcontractor used by the Disclosing Party in including but not limited to all persons or legal entities disclosed )f Subcontractors and Other Retained Parties"); mea ling a person or entity that, directly or indirectly: controls the oy the Disclosing Party, or is, with the Disclosing Party, under peison or entity). Indicia of control include, without limitation: ownership; identity of interests among family members, shared comnjon use of employees; or organization of a business entity following
i to do business with federal or state or local government, substantially the same management, ownership, or principals as the
'another
to Contractors, the term Affiliated Entity means a person or entity controls the Contractor, is controlled by it, or, with the Contractor, is person or entity; Disclosing Party, any Contractor or any Affiliated Entity or any e of the Disclosing Party, any Contractor or any Affiliated Entity, or authorization of a responsible official of the Disclosing Party, i Entity (collectively "Agents").
Page 5 of 15
Entity of either the Disclosing the date of this EDS, or, with a Contractor during the 5 years engagement in connection with the
cf
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Party or any Contractor, nor any Agents have, during the 5 years before respect to a Contractor, an Affiliated Entity, or an Affiliated Entity before the date of such Contractor's or Affiliated Entity's contract or Matter:
a. bribed or attempted to bribe, or been convicted or adjudged gui a public officer or employee of the City, the State of Illinois, or any or of any state or local government in the United States of America, official capacity;
of bribery or attempting to bribe, igency of the federal government in that officer's or employee's
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 subparagraph (a[) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
d. violated the provisions referenced in MCC Subsection 2-92-320( Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage
a)(4)(Contracts Requiring a Base inance).
, or any of their employees, of state or local government as a of 720 ILCS 5/33E-3; (2) of any state or of the United bid-rigging or bid-rotating.
6. Neither the Disclosing Party, nor any Affiliated Entity or Contractor officials, agents or partners, is barred from contracting with any unit result of engaging in or being convicted of (1) bid-rigging in violation bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense States of America that contains the same elements as the offense of
a Sanctions List maintained by the successor federal agency.
7. Neither the Disclosing Party nor any Affiliated Entity is listed on United States Department of Commerce, State, or Treasury, or any
co
Ar.pl
ntrolling person" [see MCC
icant is currently indicted or or placed under supervision for, bribery, theft, fraud, forgery, or any "sister agency"; and (ii) Article I is a continuing requirement I applies to the Applicant, that iance timeframes in this Section V.
C ty
8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any " Chapter 1-23, Article I for applicability and defined terms] of the charged with, or has admitted guilt of, or has ever been convicted of. any criminal offense involving actual, attempted, or conspiracy to ccjmmit perjury, dishonesty of deceit against an officer or employee of the the Applicant understands and acknowledges that compliance with for doing business with the City. NOTE: If MCC Chapter 1-23, Artjcle Article's permanent compliance timeframe supersedes 5-year compl
will not use, nor permit their by the U.S. EPA on the federal
9. [FOR APPLICANT ONLY] The Applicant and its Affiliated Entities subcontractors to use, any facility listed as having an active exclusion System for Award Management ("SAM").
contractors/subcontractors hired
10. [FOR APPLICANT ONLY] The Applicant will obtain from any or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior writtep consent of the City, use any such
Ver.2018-1 Page 6 of 15
contractor/subcontractor that doe: believe has not provided or cannc 11. If the Disclosing Party is una Certifications), the Disclosing Pa N/A ; not provide such certifications or that the Applicant has reason to t provide truthful certifications. ble to certify to any of the above statements in this Part B (Further ty must explain below:
If the letters "NA," the word "Noi presumed that the Disclosing Part 12. To the best of the Disclosing I complete list of all current emplo1 month period preceding the date c of Chicago (if none, indicate with N/A te," or no response appears on the lines above, it will be conclusively y certified to the above statements. 'arty's knowledge after reasonable inquiry, the following is a zees of the Disclosing Party who were, at any time during the 12-if this EDS, an employee, or elected or appointed official, of the City "N/A" or "none").
13. To the best of the Disclosing I complete list of all gifts that the E the 12-month period preceding th official, of the City of Chicago. I made generally available to City e the course of official City busines political contribution otherwise di "none"). As to any gift listed belc N/A 'arty's knowledge after reasonable inquiry, the following is a isclosing Party has given or caused to be given, at any time during i execution date of this EDS, to an employee, or elected or appointed or purposes of this statement, a "gift" does not include: (i) anything mployees or to the general public, or (ii) food or drink provided in 5 and having a retail value of less than $25 per recipient, or (iii) a ily reported as required by law (if none, indicate with "N/A" or w, please also list the name of the City recipient.
C. CERTIFICATION OF STATI 1. The Disclosing Party certifies | [is y is not a "financial institution" as defi 2. If the Disclosing Party IS a fin "We are not and will not become ; pledge that none of our affiliates i MCC Chapter 2-32. We understa predatory lender may result in the Ver.2018-1 JS AS FINANCIAL INSTITUTION :hat the Disclosing Party (check one) ned in MCC Section 2-32-455(b). ancial institution, then the Disclosing Party pledges: i predatory lender as defined in MCC Chapter 2-32. We further s, and none of them will become, a predatory lender as defined in id that becoming a predatory lender or becoming an affiliate of a loss of the privilege of doing business with the City." Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or ar y of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
ines above, it will be statements.
If the letters "NA," the word "None," or no response appears on the conclusively presumed that the Disclosing Party certified to the abo^e
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D
1. In accordance with MCC Section 2-156-110: To the best of the after reasonable inquiry, does any official or employee of the City her own name or in the name of any other person or entity in the Majtter?
0No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) a!nd D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
permitted, no City elected lame or in the name of any to the City, or (ii) is sold for <|uit of the City (collectively, the City's eminent domain tjhis Part D.
2. Unless sold pursuant to a process of competitive bidding, or othelrwise official or employee shall have a financial interest in his or her own other person or entity in the purchase of any property that (i) belong; taxes or assessments, or (iii) is sold by virtue of legal process at the "City Property Sale"). Compensation for property taken pursuant to power does not constitute a financial interest within the meaning of
Does the Matter involve a City Property Sale?
? Yes [/]No
addresses of the City officials the financial interest:
3. If you checked "Yes" to Item D(l), provide the names and business or employees having such financial interest and identify the nature o
Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financia acquired by any City official or employee.
Page 8 of 15
NG SLAVERY ERA BUSINESS
Please check either (1) or (2) must disclose below or in an attach comply with these disclosure requ connection with the flatter voidable
>eIow. If the Disclosing Party checks (2), the Disclosing Party ment to this EDS all information required by (2). Failure to irements may make any contract entered into with the City in by the City.
and
the Disclosing Party from slavery or issued to slaveholders the Disclosing Party
verifies that the Disclosing Party has searched any and all records of ill predecessor entities regarding records of investments or profits slaveholder insurance policies during the slavery era (including insurance policies that provided coverage for damage to or injury or death of their slaves), and found no such records.
has
1 1 2. The Disclosing Party verifies
Disclosing Party has found recorqs policies. The Disclosing Party records, including the names of
any;
that, as a result of conducting the search in step (1) above, the of investments or profits from slavery or slaveholder insurance ve|rifies that the following constitutes full disclosure of all such and all slaves or slaveholders described in those records:
SECTION VI » CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally federally funded, proceed to the City and proceeds of debt
oblig
funded, complete this Section VI. If the Matter is not Section VII. For purposes of this Section VI, tax credits allocated by ations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of al Disclosure Act of 1995, as amendbd Party with respect to the Matter: (
persons or entities registered under the federal Lobbying
, who have made lobbying contacts on behalf of the Disclosing \dd sheets if necessary):
(If no explanation appears or begi appear, it will be conclusively registered under the Lobbying Di< behalf of the Disclosing Party wit
1 is
on the lines above, or if the letters "NA" or if the word "None" presumed that the Disclosing Party means that NO persons or entities closure Act of 1995, as amended, have made lobbying contacts on l respect to the Matter.)
2. The Disclosing Party has n any person or entity listed in para< person or entity to influence or a by applicable federal law, a me Vcr.2018-1
Dt spent and will not expend any federally appropriated funds to pay raph A(l) above for his or her lobbying activities or to pay any ttbmpt to influence an officer or employee of any agency, as defined mfjer of Congress, an officer or employee of Congress, or an employee s Page 9 of 15
funded contract, making any or to extend, continue, renew, agreement.
of a member of Congress, in connection with the award of any federally federally funded grant or loan, entering into any cooperative agreement amend, or modify any federally funded contract, grant, loan, or cooperative
the end of each calendar quarter in he statements and information set
3. The Disclosing Party will submit an updated certification at which there occurs any event that materially affects the accuracy of forth in paragraphs A(l) and A(2) above.
described in section described in section and will not engage in "Lobbying 1995, as amended.
4. The Disclosing Party certifies that either: (i) it is not an organization 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged Activities," as that term is defined in the Lobbying Disclosure Act o
nust obtain certifications equal in subcontractors before it awards contractors' certifications for the a /ailable to the City upon request.
5. If the Disclosing Party is the Applicant, the Disclosing Party form and substance to paragraphs A(l) through A(4) above from all any subcontract and the Disclosing Party must maintain all such sub duration of the Matter and must make such certifications promptly
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?
QYes 0 No
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[/]Yes __No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Comriission all reports due under the applicable filing requirements?
[J/] Yes, CZI^0 | jReports not required
/ Yes
3. Have you participated in any previous contracts or subcontracts s equal opportunity clause?
QNo
If you checked "No" to question (1) or (2) above, please provide an explanation
Page 10 of 15
SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands
A. The certifications, disclosures contract or other agreement procurement, City assistance, or of any contract or taking other it must comply with all statutes,
and acknowledgments contained in this EDS will become part of any between the Applicant and the City in connection wilh the Matter, whether other City action, and are material inducements to the City's execution ac ion with respect to the Matter. The Disclosing Party understands that ordinances, and regulations on which this EDS is based.
B. The City's Governmental Ethi obligations on persons or entities of this ordinance and a training also be obtained from the City's (312)744-9660. The Disclosing
:s Ordinance, MCC Chapter 2-156, imposes certain duties and seeking City contracts, work, business, or transactions. The full text piogram is available on line at www.cityofchicago.org/Ethics , and may Efoard of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610, arty must comply fully with this ordinance.
in
C. If the City determines that an) any contract or other agreement i or voidable, and the City may void), at law, or in equity, in< and/or declining to allow the law for a false statement of damages.
information provided in this EDS is false, incomplete or inaccurate, connection with which it is submitted may be rescinded or be void pursue any remedies under the contract or agreement (if not rescinded or eluding terminating the Disclosing Party's participation in the Matter Disc losing Party to participate in other City transactions. Remedies at material fact may include incarceration and an award to the City of treble
respo lse
D. It is the City's policy to make request. Some or all of the available on the Internet, in completing and signing this EDS. claims which it may have against contained in this EDS and also in this EDS.
his document available to the public on its Internet site and/or upon inforn|iation provided in, and appended to, this EDS may be made publicly to a Freedom of Information Act request, or otherwise. By the Disclosing Party waives and releases any possible rights or the City in connection with the public release of information authorizes the City to verify the accuracy of any information submitted
E. The information provided in Party must supplement this EDS contract being handled by the Cit^ update this EDS as the contract 1-23, Article I (imposing information provided herein by MCC Chapter 1-23 and Secti
tikis
0 1
EDS must be kept current. In the event of changes, the Disclosing i|p to the time the City takes action on the Matter. If the Matter is a 's Department of Procurement Services, the Disclosing Party must rejquires. NOTE: With respect to Matters subject to MCC Chapter PERMLlNENT INELIGIBILITY for certain specified offenses), the regarding eligibility must be kept current for a longer period, as required 2-154-020.
Page 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants tha this EDS, and all applicable Appendices, on behalf of the Disclosing certifications and statements contained in this EDS, and all applicab and complete as of the date furnished to the City.
he/she is authorized to execute Party, and (2) warrants that all e Appendices, are true, accurate
Ogden Commons MSH LLC
(Print or type exact legal name of Disclosing Party) By:
(Sign here) Jim Bicak
(Print or type name of person signing) Vice President
(Print or type title of person signing)
Signed and sworn to before me on (date)
Commission expires: /f(f
County,^ l(lmDfS> (state).
OFFICIAL SEAL RAQUEL ALCANTAR
NOTARY PUBLIC. STATE OF ILLINOIS v ".ommission Expires Oct 23, 2019
Page 12 of 15
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 direct ownership interest in the entity which has only an indiredt
only by (a) the Applicant, and (b) any legal entity which has a Applicant exceeding 7.5%. It is not to be completed by any legal ownership interest in the Applicant.
Under MCC Section 2-154-01 or any "Applicable Party" or any relationship" with any elected cit) the date this EDS is signed, the D Partner thereof is related to the department head as spouse or adoption: parent, child, brother or father-in-law, mother-in-law, son stepdaughter, stepbrother or stepsiste
5, the Disclosing Party must disclose whether such Disclosing Party Spouse or Domestic Partner thereof currently has a "familial official or department head. A "familial relationship" exists if, as of sclosing Party or any "Applicable Party" or any Spouse or Domestic mayor, any alderman, the city clerk, the city treasurer or any city donjiestic partner or as any of the following, whether by blood or sister, aunt or uncle, niece or nephew, grandparent, grandchild, in-law, daughter-in-law, stepfather or stepmother, stepson or r or half-brother or half-sister.
"Applicable Party" means (1) II.B.l.a., if the Disclosing Party ii Party is a general partnership; all Disclosing Party is a limited partnership Disclosing Party, if the Disclosing Disclosing Party; and (3) any pen on Party. "Principal officers" means financial officer, treasurer or secretary
all executive officers of the Disclosing Party listed in Section a corporation; all partners of the Disclosing Party, if the Disclosing eneral partners and limited partners of the Disclosing Party, if the
; all managers, managing members and members of the Party is,a limited liability company; (2) all principal officers of the having more than a 7.5% ownership interest in the Disclosing (jhe president, chief operating officer, executive director, chief of a legal entity or any person exercising similar authority.
Does the Disclosing Party or currently have a "familial relation
ajny "Applicable Party" or any Spouse or Domestic Partner thereof hip" with an elected city official or department head?
? Yes
If yes, please identify below ( which such person is connected; whom such person has a familial
) the name and title of such person, (2) the name of the legal entity to (3) the name and title of the elected city official or department head to relationship, and (4) the precise nature of such familial relationship.
Page 13 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
any legal entity which has a direct
This Appendix is to be completed only by (a) the Applicant, and (b)
ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the App icant.
1. Pursuant to MCC Section 2-154-010, is the Applicant or any Ow[ier identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
QYes
2. If the Applicant is a legal entity publicly traded on any exchange the Applicant identified as a building code scofflaw or problem land 2-92-416?
is any officer or director of ord pursuant to MCC Section
| |No |^|The Applicant is not publicly traded on any exchange
person or legal entity identified efich building or buildings to which
3. If yes to (1) or (2) above, please identify below the name of each as a building code scofflaw or problem landlord and the address of the pertinent code violations apply.
Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
E & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed defined in MCC Section 2-92-3ST generally covers a party to any consideration for services, work or (ii) pay the City money for a 1 City premises.
only by an Applicant that is completing this EDS as a "contractor" as . That section, which should be consulted (www.amlegal.com ), agreement pursuant to which they: (i) receive City of Chicago funds in goods provided (including for legal or other professional services), itense, grant or concession allowing them to conduct a business on
contractor pursuant to MCC Section 2-92-385,1 hereby certify that h MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening or salary history, or (ii) seeking job applicants' wage or salary
I also certify that the Applicant has adopted a policy that
On behalf of an Applicant that is the Applicant is in compliance wi job applicants based on their wage history from current or former employers includes those prohibitions.
L7]Yes QNo
[ |N/A -1 am not an Applicant ttat is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as thfe affidavit required by MCC Section 2-92-385(c)(l).
If you checked "no" to the above,
Page 15 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing MOUNT SINAI HOSPITAL MED
Party submitting this EDS. Include d/b/a/ if applicable: CAL CENTER OF CHICAGO
Check ONE ofthe following three boxes
Indicate whether the Disclosing Pjarty submitting this EDS is
I ] the Applicant,
holding, or anticipated to hold within six months after City action on Undertaking to which this EDS pertains (referred to below as the in excess of 7.5% in the Applicant. State the Applicant's legal
OR
|y| a legal entity currently the contract, transaction or other "Matter"), a direct or indirect interest name: ogden washtenaw jv llc
OR
3. ?) a legal entity with a State the legal name of the entity
or indirect right of control of the Applicant (see Section 11(B)(1)) in which the Disclosing Party holds a right of control:
B. Business address of the Disclc
Chicago, IL 60608
C. Telephone: (773)257-5011
D. Name of contact person: Jesse
E. Federal Employer Identification No. (if you have one):
to which this EDS pertains. (Include project number and location of
F. Brief description of the Mattel property, if applicable):
Applicant is seeking Neighborhood Opportunity Zone fu ids to assist with tho development of a mixed use project at West Ogden Ave. and Washtenaw Ave Chicago
If the Matter is a contract being hi, complete the following:
Specification #
Ver.2018-1
G. Which City agency or departnjent is requesting this EDS? Department of Planning & Development
ndled by the City's Department of Procurement Services, please
and Contract #
Page 1 of 15
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 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))? ? No
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable
ILLINOIS
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 [7] Organized in Illi lois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
officers and all directors of vhich are legal entities (if there (iii) for trusts, estates or other
party; (iv) for general or partnerships or joint ventures, or legal entity that directly or
1. List below the full names and titles, if applicable, of: (i) all executive the entity; (ii) for not-for-profit corporations, all members, if any, are no such members, write "no members which are legal entities"); similar entities, the trustee, executor, administrator, or similarly situated limited partnerships, limited liability companies, limited liability each general partner, managing member, manager or any other persoh indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
See Exhibit "A"
Sinai Health System|99|Sole Member
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% of the Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
Page 2 of 15
limited liability company, or inte state "None." NOTE: Each legal entity listed b Name Busine Sinai Health System 1500 S. Ca est of a beneficiary of a trust, estate or other similar entity. If none, slow may be required to submit an EDS on its own behalf. ;s Address Percentage Interest in the Applicant ifomia Ave., Chicago, IL 60608 20%
SECTION III -- INCOME OR OFFICIALS Has the Disclosing Party provide 12-month period preceding the d< Does the Disclosing Party reason elected official during the 12-moi If "yes" to either of the above, pie describe such income or compens COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED i any income or compensation to any City elected official during the te of this EDS? 0Yes [7]No ibly expect to provide any income or compensation to any City ith period following the date of this EDS? | | Yes ^ No ase identify below the name(s) of such City elected official(s) and ation:
Does any City elected official or, inquiry, any City elected official1 Chapter 2-156 of the Municipal C 0Yes [/]N If "yes," please identify below the partner(s) and describe the financ to the best of the Disclosing Party's knowledge after reasonable ; spouse or domestic partner, have a financial interest (as defined in !ode of Chicago ("MCC")) in the Disclosing Party? ) name(s) of such City elected official(s) and/or spouse(s)/domestic ial interest(s).
1 1V /11 1 Y — It IlIVI/V/lI vj ivr The Disclosing Party must disclo: lobbyist (as defined in MCC Cha] whom the Disclosing Party has re the nature ofthe relationship, and Disclosing Party is not required t( Party's regular payroll. If the Dis Section, the Disclosing Party mus disclosure. Vcr.2018-1 ,e the name and business address of each subcontractor, attorney, )ter 2-156), accountant, consultant and any other person or entity tained or expects to retain in connection with the Matter, as well as the total amount of the fees paid or estimated to be paid. The disclose employees who are paid solely through the Disclosing closing Party is uncertain whether a disclosure is required under this t either ask the City whether disclosure is required or make the Page 3 of 15
j
Name (indicate whether retained or anticipated to be retained)
NONE
Business Relationship to Disclosing Address (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NOTE: "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 t(f) retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC 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 co npetent jurisdiction?
QYes QNo [/]No person directly or indirectly ov/ns 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?
by the City's Department of EDS, neither the Disclosing
in connection with the , independent private sector ijial or entity with legal, auditing, help the agency monitor the
their business practices so they a contract in progress).
QYes QNo
FURTHER CERTIFICATIONS
1. [This paragraph 1 applies only if the Matter is a contract being habdled Procurement Services.] In the 5-year period preceding the date of th s Party nor any Affiliated Entity [see definition in (5) below] has engaged performance of any public contract, the services of an integrity monitor inspector general, or integrity compliance consultant (i.e., an individ investigative, or other similar skills, designated by a public agency tc activity of specified agency vendors as well as help the vendors reform can be considered for agency contracts in the future, or continue witl
2. The Disclosing Party and its Affiliated Entities are not delinquent tax or other source of indebtedness owed to the City of Chicago and sewer charges, license fees, parking tickets, property taxes and sa Party delinquent in the payment of any tax administered by the Illino
Page 4 of 15
3. The Disclosing Party and, if tie Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) of t lis EDS:
ded, proposed for debarment, declared ineligible or voluntarily any federal, state or local unit of government;
b. have not, during the 5 years adjudged guilty, or had a civil ju attempting to obtain, or performijig public transaction; a violation of bribery; falsification or destructi
before the date of this EDS, been convicted of a criminal offense, dgment rendered against them in connection with: obtaining,
on
a public (federal, state or local) transaction or contract under a federal or state antitrust statutes; fraud; embezzlement; theft; forgery; of records; making false statements; or receiving stolen property;
c. are not presently indicted for, state or local) with committing
or criminally or civilly charged by, a governmental entity (federal, of the offenses set forth in subparagraph (b) above;
d. have not, during the 5 years (federal, state or local) terminated
before the date of this EDS, had one or more public transactions for cause or default; and
e. have not, during the 5 years before liable in a civil proceeding, or in environmental violations, institut unit of local government.
the date of this EDS, been convicted, adjudged guilty, or found any criminal or civil action, including actions concerning jd by the City or by the federal government, any state, or any other
nds and shall comply with the applicable requirements of MCC and 2-156 (Governmental Ethics).
; iny contractor or subcontractor used by the Disclosing Party in ir eluding but not limited to all persons or legal entities disclosed of Subcontractors and Other Retained Parties"); meaning a person or entity that, directly or indirectly: controls the by the Disclosing Party, or is, with the Disclosing Party, under pejrson or entity). Indicia of control include, without limitation: rship; identity of interests among family members, shared common use of employees; or organization of a business entity following
entity to do business with federal or state or local government, subs antially the same management, ownership, or principals as the
to Contractors, the term Affiliated Entity means a person or entity ols the Contractor, is controlled by it, or, with the Contractor, is er person or entity;
the
10 1
Disclosing Party, any Contractor or any Affiliated Entity or any ee of the Disclosing Party, any Contractor or any Affiliated Entity, or authorization of a responsible official of the Disclosing Party, d Entity (collectively "Agents").
Page 5 of 15
Zntity of either the Disclosing re the date of this EDS, or, with a Contractor during the 5 years sngagement in connection with the
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Party or any Contractor, nor any Agents have, during the 5 years bef{) respect to a Contractor, an Affiliated Entity, or an Affiliated Entity o before the date of such Contractor's or Affiliated Entity's contract or Matter:
a. bribed or attempted to bribe, or been convicted or adjudged guilt) a public officer or employee of the City, the State of Illinois, or any < or of any state or local government in the United States of America official capacity;
of bribery or attempting to bribe, gency of the federal government that officer's or employee's
a party to any such agreement, bidders or prospective bidders, or otherwise; or
b. agreed or colluded with other bidders or prospective bidders, or been or been convicted or adjudged guilty of agreement or collusion amo ig in restraint of freedom of competition by agreement to bid a fixed pn ce
c. made an admission of such conduct described in subparagraph (a record, but have not been prosecuted for such conduct; or
)(4)(Contracts Requiring a Base Ordinance).
d. violated the provisions referenced in MCC Subsection 2-92-320( Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage
, or any of their employees, Df state or local government as a of720TLCS5/33E-3; (2)
of any state or of the United -rigging or bid-rotating.
hid
6. Neither the Disclosing Party, nor any Affiliated Entity or Contracltor, officials, agents or partners, is barred from contracting with any unit result of engaging in or being convicted of (1) bid-rigging in violatioin bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense States of America that contains the same elements as the offense of
a Sanctions List maintained by the successor federal agency.
7. Neither the Disclosing Party nor any Affiliated Entity is listed on United States Department of Commerce, State, or Treasury, or any
"ccn
trolling person" [see MCC nt is currently indicted or or placed under supervision for, bribery, theft, fraud, forgery, or any "sister agency"; and (ii) rticle I continuing requirement Article I applies to the Applicant, that i ince timeframes in this Section V.
Ci :y
8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any " Chapter 1-23, Article I for applicability and defined terms] of the Apblica: charged with, or has admitted guilt of, or has ever been convicted of, any criminal offense involving actual, attempted, or conspiracy to cofrimit perjury, dishonesty or deceit against an officer or employee of the
vpplicant understands and acknowledges that compliance with
for doing business with the City. NOTE: If MCC Chapter 1-23, Article's permanent compliance timeframe supersedes 5-year compl
will not use, nor permit their by the U.S. EPA on the federal
9. [FOR APPLICANT ONLY] The Applicant and its Affiliated Entities subcontractors to use, any facility listed as having an active exclusion System for Award Management ("SAM").
10. [FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in foim and substance to those in Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
Ver.2018-1 lJ;me6ol'15
contractor/subcontractor that doe believe has not provided or cannc 11. If the Disclosing Party is urn Certifications), the Disclosing Pa N/A ; not provide such certifications or that the Applicant has reason to t provide truthful certifications. ble to certify to any of the above statements in this Part B (Further ty must explain below:
Ifthe letters "NA," the word "No presumed that the Disclosing Pari 12. To the best of the Disclosing complete list of all current emplo month period preceding the date c of Chicago (if none, indicate with N/A ie," or no response appears on the lines above, it will be conclusively y certified to the above statements. 'arty's knowledge after reasonable inquiry, the following is a ^ees of the Disclosing Party who were, at any time during the 12->f this EDS, an employee, or elected or appointed official, of the City "N/A" or "none").
13. To the best of the Disclosing 1 complete list of all gifts that the E the 12-month period preceding th official, of the City of Chicago. I made generally available to City t the course of official City busines political contribution otherwise di "none"). As to any gift listed belc N/A 'arty's knowledge after reasonable inquiry, the following is a isclosing Party has given or caused to be given, at any time during ; execution date of this EDS, to an employee, or elected or appointed or purposes of this statement, a "gift" does not include: (i) anything mployees or to the general public, or (ii) food or drink provided in 5 and having a retail value of less than $25 per recipient, or (iii) a ily reported as required by law (if none, indicate with "N/A" or w, please also list the name of the City recipient.
C. CERTIFICATION OF ST ATI 1. The Disclosing Party certifies | | is [7] is not a "financial institution" as defi 2. If the Disclosing Party IS a fin "We are not and will not become ; pledge that none of our affiliates i MCC Chapter 2-32. We understa: predatory lender may result in the IS AS FINANCIAL INSTITUTION that the Disclosing Party (check one) ned in MCC Section 2-32-455(b). ancial institution, then the Disclosing Party pledges: predatory lender as defined in MCC Chapter 2-32. We further >, and none of them will become, a predatory lender as defined in id that becoming a predatory lender or becoming an affiliate of a loss of the privilege of doing business with the City."
Page 7 of 15
of its affiliates (as defined in of MCC Chapter 2-32, explain
If the Disclosing Party is unable to make this pledge because it or any MCC Section 2-32-455(b)) is a predatory lender within the meaning here (attach additional pages if necessary):
ijines above, it will be statements.
Ifthe letters "NA," the word "None," or no response appears on the conclusively presumed that the Disclosing Party certified to the abo^e
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same n.eanings if used in this Part D
E isclosing Party's knowledge halve a financial interest in his or
1. In accordance with MCC Section 2-156-110: To the best of the after reasonable inquiry, does any official or employee of the City her own name or in the name of any other person or entity in the Matter?
QYes
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) a^id D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
this
Does the Matter involve a City Property Sale?
addresses of the City officials the financial interest:
? Yes [/] No
3. If you checked "Yes" to Item D(l), provide the names and business or cmDlovees havins such financial interest and identify the nature o
of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial acquired by any City official or employee.
Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) must disclose below or in an attach comply with these disclosure re connection with the Matter voidable
Delow. If the Disclosing Party checks (2), the Disclosing Party ment to this EDS all information required by (2). Failure to qhirements may make any contract entered into with the City in by the City.
ded
that the Disclosing Party has searched any and all records of all predecessor entities regarding records of investments or profits policies during the slavery era (including insurance policies coverage for damage to or injury or death of their slaves), and such records.
Disclosing Party has found records policies. The Disclosing Party records, including the names of
I 1 2. The Disclosing Party ver fies that, as a result of conducting the search in step (1) above, the
a ly
of investments or profits from slavery or slaveholder insurance verifies that the following constitutes full disclosure of all such and all slaves or slaveholders described in those records:
ONS FOR FEDERALLY FUNDED MATTERS
NOTE. If the Matter is federal
y funded, complete this Section VI. If the Matter is not federally funded, proceed to Sec ion VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obli gations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all Disclosure Act of 1995, as amend Party with respect to the Matter: (
persons or entities registered under the federal Lobbying :d, who have made lobbying contacts on behalf of the Disclosing \dd sheets if necessary):
ins
(If no explanation appears or beg appear, it will be conclusively presume registered under the Lobbying Dis behalf of the Disclosing Party wi
it! i
on the lines above, or if the letters "NA" or if the word "None" d that the Disclosing Party means that NO persons or entities sblosure Act of 1995, as amended, have made lobbying contacts on respect to the Matter.)
2. The Disclosing Party has any person or entity listed in paragra person or entity to influence or attc by applicable federal law, a membp Ver.2018-1 !
spent and will not expend any federally appropriated funds to pay ph A(l) above for his or her lobbying activities or to pay any mpt to influence an officer or employee of any agency, as defined r of Congress, an officer or employee of Congress, or an employee Pace 9 of 15
funded contract, making any , or to extend, continue, renew, agreement.
of a member of Congress, in connection with the award of any federally federally funded grant or loan, entering into any cooperative agreement amend, or modify any federally funded contract, grant, loan, or cooperative
3. The Disclosing Party will submit an updated certification at which there occurs any event that materially affects the accuracy of forth in paragraphs A(l) and A(2) above.
end of each calendar quarter in tjhe statements and information set
described in section n described in section and will not engage in "Lobbying 1995, as amended.
4. The Disclosing Party certifies that either: (i) it is not an organization 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organ zatio 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged Activities," as that term is defined in the Lobbying Disclosure Act of
must obtain certifications equal in subcontractors before it awards certifications for the to the City upon request.
5. If the Disclosing Party is the Applicant, the Disclosing Party form and substance to paragraphs A(l) through A(4) above from all any subcontract and the Disclosing Party must maintain all such subcontractors duration of the Matter and must make such certifications promptly available
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OP
Applicant and all proposed in writing at the outset of
If the Matter is federally funded, federal regulations require the subcontractors to submit the following information with their bids or
negotiations.
/ No
Is the Disclosing Party the Applicant? ? Yes
If "Yes," answer the three questions below:
Yes
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
QNo
)f the Office of Federal Contract all reports due under the
2. Have you filed with the Joint Reporting Committee, the Director Compliance Programs, or the Equal Employment Opportunity Corrmiission applicable filing requirements?
[/] Yes CZI^0 [ [Reports not required
Yes
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
~ QNo
/
If you checked "No" to question (1) or (2) above, please provide an explanation
Page 10 of 15
SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands
A. The certifications, disclosures contract or other agreement between procurement, City assistance, or of any contract or taking other action it must comply with all statutes,
crd
and acknowledgments contained in this EDS will become part of any the Applicant and the City in connection with the Matter, whether rjther City action, and are material inducements to the City's execution with respect to the Matter. The Disclosing Party understands that inances, and regulations on which this EDS is based.
i:s
Ordinance, MCC Chapter 2-156, imposes certain duties and seeking City contracts, work, business, or transactions. The full text m is available on line at www.cityofchicago.org/Ethics , and may B|oard of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610, arty must comply fully with this ordinance.
C. If the City determines that an any contract or other agreement iiti or voidable, and the City may purs void), at law, or in equity, includi and/or declining to allow the Disdlosing law for a false statement of mater damages.
information provided in this EDS is false, incomplete or inaccurate, connection with which it is submitted may be rescinded or be void ue any remedies under the contract or agreement (if not rescinded or ng terminating the Disclosing Party's participation in the Matter
Party to participate in other City transactions. Remedies at al fact may include incarceration and an award to the City of treble
D. It is the City's policy to make request. Some or all of the infornjiation available on the Internet, in respo ise completing'and signing this EDS. claims which it may have against contained in this EDS and also authorizes in this EDS.
his document available to the public on its Internet site and/or upon provided in, and appended to, this EDS may be made publicly to a Freedom of Information Act request, or otherwise. By the Disclosing Party waives and releases any possible rights or the City in connection with the public release of information
the City to verify the accuracy of any information submitted
this
up
E. The information provided in Party must supplement this EDS contract being handled by the Cit| update this EDS as the contract requires 1-23, Article I (imposing PERMANENT information provided herein regard by MCC Chapter 1-23 and Sectio
EDS must be kept current. In the event of changes, the Disclosing to the time the City takes action on the Matter. If the Matter is a 's Department of Procurement Services, the Disclosing Party must NOTE: With respect to Matters subject to MCC Chapter INELIGIBILITY for certain specified offenses), the ing eligibility must be kept current for a longer period, as required 2-154-020.
Page 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants fha this EDS, and all applicable Appendices, on behalf of the Disclosing certifications and statements contained in this EDS, and all applicabl and complete as of the date furnished to the City.
he/she is authorized to execute Party, and (2) warrants that all e Appendices, are true, accurate
Mount Sinai Hospital Medical Center of Chicago
(Print or type ^xact legal name/fff Disclosing Party)
C(5lgirhere) Airica Steed
(Print or type name of person signing) EVP/COO
(Print or type title of person signing)
Signed and sworn to before me on (date) |fl/|/i[\(\f[ (jjjulOlty ,
'^SAM ARELLANO issSCpf?teof''«noiS
at PNk, . cou„,y, .niiiirk
Commission expires: ^[ %D|^/)/7"()
ROSA Notary
Page 12 of 15
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 direct ownership interest in the entity which has only an indirect
only by (a) the Applicant, and (b) any legal entity which has a Applicant exceeding 7.5%. It is not to be completed by any legal ownership interest in the Applicant.
-015
ity
Under MCC Section 2-154 or any "Applicable Party" or any relationship" with any elected ci the date this EDS is signed, the Partner thereof is related to the department head as spouse or dorhestic adoption: parent, child, brother oi father-in-law, mother-in-law, son stepdaughter, stepbrother or stepsister
, the Disclosing Party must disclose whether such Disclosing Party Spouse or Domestic Partner thereof currently has a "familial official or department head. A "familial relationship" exists if, as of Disclosing Party or any "Applicable Party" or any Spouse or Domestic m lyor, any alderman, the city clerk, the city treasurer or any city partner or as any of the following, whether by blood or sister, aunt or uncle, niece or nephew, grandparent, grandchild, in-law, daughter-in-law, stepfather or stepmother, stepson or or half-brother or half-sister.
"Applicable Party" means (1) II.B.l.a., if the Disclosing Party i$ Party is a general partnership; all Disclosing Party is a limited partnership Disclosing Party, if the Disclosing Disclosing Party; and (3) any person Party. "Principal officers" means financial officer, treasurer or
ill executive officers of the Disclosing Party listed in Section a corporation; all partners of the Disclosing Party, if the Disclosing general partners and limited partners of the Disclosing Party, if the ; all managers, managing members and members of the Party is a limited liability company; (2) all principal officers of the
having more than a 7.5% ownership interest in the Disclosing he president, chief operating officer, executive director, chief secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or currently have a "familial
ajny "Applicable Party" or any Spouse or Domestic Partner thereof relationship" with an elected city official or department head?
? Yes
If yes, please identify below (
) the name and title of such person, (2) the name of the legal entity to
whom such person has a familial
which such person is connected; (3) the name and title of the elected city official or department head to
eiationship, and (4) the precise nature of such familial relationship.
Page 13 of" 15
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) ownership interest in the Applicant exceeding 7.5% (an "Owner"). ] legal entity which has only an indirect ownership interest in the App
any legal entity which has a direct is not to be completed by any
icant.
1. Pursuant to MCC Section 2-154-010, is the Applicant or any Owher identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
| | Yes
2. If the Applicant is a legal entity publicly traded on any exchange the Applicant identified as a building code scofflaw or problem land 2-92-416?
is any officer or director of ord pursuant to MCC Section
J The Applicant is not publicly traded on any exchange.
person or legal entity identified each building or buildings to which
3. If yes to (1) or (2) above, please identify below the name of each as a building code scofflaw or problem landlord and the address of the pertinent code violations apply.
Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WACJE & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed defined in MCC Section 2-92-385 generally covers a party to any consideration for services, work or (ii) pay the City money for a 1 City premises.
only by an Applicant that is completing this EDS as a "contractor" as . That section, which should be consulted (www.amlegal.com ), agreement pursuant to which they: (i) receive City of Chicago funds in goods provided (including for legal or other professional services), ibense, grant or concession allowing them to conduct a business on
a contractor pursuant to MCC Section 2-92-385,1 hereby certify that th MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening or salary history, or (ii) seeking job applicants' wage or salary oyers. I also certify that the Applicant has adopted a policy that
rmpl
On behalf of an Applicant that is the Applicant is in compliance w job applicants based on their wagje history from current or former e includes those prohibitions.
[/]Yes
QNo
| |N/A -1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as trie affidavit required by MCC Section 2-92-385(c)(l). If you checked "no" to the above] please explain.
Page 15 of 15
!
Attachment A
SECTION II - DISCLOSURE Part B - Supplement
Name
Karen Teitelbaum Airica Steed Rachel Dvorken Debra Wesley Robert Markin Laurie Hernandez Albert Grace Roxanne Decyk
Title
Presidert & Chief Executive Officer Executiv s Vice President/Chief Operating Officer Executive Vice President, General Counsel Executivs Vice President/President of Sinai Community Institute Board Directors Officer Board Directors Officer Board Directors Officer Board Directors Officer
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -- GENERAL INFORMATION
A. Legal name of the Disclosing SINAI HEALTH SYSTEM
Check ONE of the following three boxes
Indicate whether the Disclosing Party submitting this EDS is
| | the Applicant
holding, or anticipated to hold within six months after City action on jndertaking to which this EDS pertains (referred to below as the in excess of 7.5% in the Applicant. State the Applicant's legal
OR
|/| a legal entity currently the contract, transaction or other "Matter"), a direct or indirect interest name: ogden washtenaw jv llc
OR
3. | | a legal entity with a di State the legal name of the entity
ect or indirect right of control of the Applicant (see Section 11(B)(1)) in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: 1500 s. California Ave.
Chicago, IL 60608
C. Telephone: (773)257-5011
\. Green
Name of contact person: -lesse
Federal Employer Identification No. (if you have one):
to which this EDS pertains. (Include project number and location of
Applicant is seeking Neighborhood Opportunity Zone fu ids to assist with the development of a mixed use project at West Ogden Ave and Washtenaw Ave . Chicago
G. Which City agency or departnjient is requesting this EDS? Department of Planning & Development
indled by the City's Department of Procurement Services, please
and Contract #
If the Matter is a contract being h complete the following:
Page 1 of 15
Specification #
Ver.2018-1
- 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
/
TTS-
Soration also a 501(c)(3))? Mo
[ ] Other (please specify)
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 [/J Organized in Ulii ois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all exec utive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability
each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its ow i behalf.
Name
See Exhibit "A"
No Members which are legal entities
or legal entity having a direct or ) beneficial interest (including interest include shares in a
of a member or manager in a
2. Please provide the following information concerning each person indirect, current or prospective (i.e. within 6 months after City action ownership) in excess of 7.5% of the Applicant. Examples of such an corporation, partnership interest in a partnership or joint venture, interest
Page 2 of 15
limited liability company, or inte state "None." NOTE: Each legal entity listed b ^ame Busine est of a beneficiary of a trust, estate or other similar entity. If none, ilow may be required to submit an EDS on its own behalf. ;s Address Percentage Interest in the Applicant
None
SECTION III -- INCOME OR OFFICIALS Has the Disclosing Party provide 12-month period preceding the d; Does the Disclosing Party reason elected official during the 12-mot If "yes" to either of the above, pie describe such income or compens i COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED 1 any income or compensation to any City elected official during the te of this EDS? [HYes / No ibly expect to provide any income or compensation to any City )th period following the date of this EDS? ?] Yes / No ase identify below the name(s) of such City elected official(s) and ation:
Does any City elected official or, inquiry, any City elected official' Chapter 2-156 of the Municipal C QYes [/]N If "yes," please identify below th< partner(s) and describe the financ to the best of the Disclosing Party's knowledge after reasonable ; spouse or domestic partner, have a financial interest (as defined in !ode of Chicago ("MCC")) in the Disclosing Party? : name(s) of such City elected official(s) and/or spouse(s)/domestic ial interest(s).
SECTION IV » DISCLOSURI The Disclosing Party must disclo lobbyist (as defined in MCC Chaj whom the Disclosing Party has re the nature of the relationship, and Disclosing Party is not required t< Party's regular payroll. If the Dis Section, the Disclosing Party mu? disclosure. OF SUBCONTRACTORS AND OTHER RETAINED PARTIES ;e the name and business address of each subcontractor, attorney, 5ter 2-156), accountant, consultant and any other person or entity tained or expects to retain in connection with the Matter, as well as the total amount of the fees paid or estimated to be paid. The ) disclose employees who are paid solely through the Disclosing :losing Party is uncertain whether a disclosure is required under this t either ask the City whether disclosure is required or make the
Page 3 of 15
Name (indicate whether retained or anticipated to be retained)
Business Relationship to Disclosing Address (subcontractor, attorney, lobbyist, etc.)
Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.
NONE
(Add sheets if necessary)
| |Check here if the Disclosing Party has not retained, nor expects td> retain, any such persons or entities. SECTION V -- CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entitle > remain in compliance with their child support obligations throughout
Disclosing Party been declared in co: npetent jurisdiction?
Has any person who directly or indirectly owns 10% or more of the arrearage on any child support obligations by any Illinois court of
QYes QNo [/INo person directly or indirectly owns 10% or more of the Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for jayment of all support owed and is the person in compliance with that agreement?
QYes QNo
B. FURTHER CERTIFICATIONS
1. [This paragraph 1 applies only if the Matter is a contract being ha idled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity moniior, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency tc activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
in the payment of any fine, fee, iding, but not limited to, water es taxes, nor is the Disclosing Department of Revenue.
2. The Disclosing Party and its Affiliated Entities are not delinquent tax or other source of indebtedness owed to the City of Chicago, incl and sewer charges, license fees, parking tickets, property taxes and sal Party delinquent in the payment of any tax administered by the Illinois
Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) of this EDS:
a. are not presently debarred, sujspe excluded from any transactions t y
nded, proposed for debarment, declared ineligible or voluntarily any federal, state or local unit of government;
b. have not, during the 5 years b adjudged guilty, or had a civil attempting to obtain, or perfo public transaction; a violation of bribery; falsification or destruct
efore the date of this EDS, been convicted of a criminal offense, judgment rendered against them in connection with: obtaining, rming a public (federal, state or local) transaction or contract under a federal or state antitrust statutes; fraud; embezzlement; theft; forgery; i0n of records; making false statements; or receiving stolen property;
c. are not presently indicted for, state or local) with committing
or criminally or civilly charged by, a governmental entity (federal, of the offenses set forth in subparagraph (b) above;
d. have not, during the 5 years (federal, state or local) terminated
before the date of this EDS, had one or more public transactions for cause or default; and
e. have not, during the 5 years b liable in a civil proceeding, or in environmental violations, i unit of local government.
efore the date of this EDS, been convicted, adjudged guilty, or found any criminal or civil action, including actions concerning nstitutjed by the City or by the federal government, any state, or any other
4. The Disclosing Party Chapters 2-56 (Inspector Genera
understands and shall comply with the applicable requirements of MCC ) and 2-156 (Governmental Ethics).
another
tie
ated
iny contractor or subcontractor used by the Disclosing Party in including but not limited to all persons or legal entities disclosed of Subcontractors and Other Retained Parties"); meaning a person or entity that, directly or indirectly: controls the by the Disclosing Party, or is, with the Disclosing Party, under person or entity). Indicia of control include, without limitation: wnership; identity of interests among family members, shared common use of employees; or organization of a business entity following ;ntity to do business with federal or state or local government, antially the same management, ownership, or principals as the to Contractors, the term Affiliated Entity means a person or entity controls the Contractor, is controlled by it, or, with the Contractor, is person or entity; Disclosing Party, any Contractor or any Affiliated Entity or any ee of the Disclosing Party, any Contractor or any Affiliated Entity, or authorization of a responsible official of the Disclosing Party, Entity (collectively "Agents").
Page 5 of 15
ntity of either the Disclosing
the date of this EDS, or, with f a Contractor during the 5 years engagement in connection with the
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Party or any Contractor, nor any Agents have, during the 5 years befbre respect to a Contractor, an Affiliated Entity, or an Affiliated Entity o before the date of such Contractor's or Affiliated Entity's contract or Matter:
a. bribed or attempted to bribe, or been convicted or adjudged guilty a public officer or employee of the City, the State of Illinois, or any or of any state or local government in the United States of America, official capacity;
of bribery or attempting to bribe, gency of the federal government that officer's or employee's
b. 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 amo ig bidders or prospective bidders, in restraint of freedom of Competition by agreement to bid a fixed pr ce or otherwise; or
c. made an admission of such conduct described in subparagraph (a record, but have not been prosecuted for such conduct; or
)(4)(Contracts Requiring a Base Ordinance).
d. violated the provisions referenced in MCC Subsection 2-92-320( Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage
Contractor, or any of their employees, of state or local government as a of 720 ILCS 5/33E-3; (2) of any state or of the United rigging or bid-rotating.
offense
tid-
6. Neither the Disclosing Party, nor any Affiliated Entity or officials, agents or partners, is barred from contracting with any unit result of engaging in or being convicted of (1) bid-rigging in violatioh bid-rotating in violation of 720 ELCS 5/33E-4; or (3) any similar States of America that contains the same elements as the offense of
7. Neither the Disclosing Party nor any Affiliated Entity is listed on United States Department of Commerce, State, or Treasury, or any
ntrolling person" [see MCC
ant is currently indicted or or placed under supervision for, bribery, theft, fraud, forgery, or any "sister agency"; and (ii) I is a continuing requirement ;le I applies to the Applicant, that ince timeframes in this Section V.
8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any "cc Chapter 1-23, Article I for applicability and defined terms] of the Applic charged with, or has admitted guilt of, or has ever been convicted of, any criminal offense involving actual, attempted, or conspiracy to cohimit perjury, dishonesty or deceit against an officer or employee of the Ci :y the Applicant understands and acknowledges that compliance with Article for doing business with the City. NOTE: If MCC Chapter 1-23, Arti Article's permanent compliance timeframe supersedes 5-year compli
Entities will not use, nor permit their by the U.S. EPA on the federal
9. [FOR APPLICANT ONLY] The Applicant and its Affiliated subcontractors to use, any facility listed as having an active exclusiorji System for Award Management ("SAM").
contractors/subcontractors hired and substance to those in consent of the City, use any such
10. [FOR APPLICANT ONLY] The Applicant will obtain from any or to be hired in connection with the Matter certifications equal in form Certifications (2) and (9) above and will not, without the prior written
Ver.2018-1 Page 6 of 15
contractor/subcontractor that does believe has not provided or canmpt
not provide such certifications or that the Applicant has reason to provide truthful certifications.
able to certify to any of the above statements in this Part B (Further
11. If the Disclosing Party is un
Certifications), the Disclosing Pajrty must explain below:
N/A
Ifthe letters "NA," the word "No presumed that the Disclosing Party
ne," or no response appears on the lines above, it will be conclusively certified to the above statements.
12. To the best of the Disclosing complete list of all current employee month period preceding the date of Chicago (if none, indicate with
N/A
arty's knowledge after reasonable inquiry, the following is a
s of the Disclosing Party who were, at any time during the 12-)f this EDS, an employee, or elected or appointed official, of the City "N/A" or "none").
13. To the best of the Disclosing complete list of all gifts that the the 12-month period preceding official, of the City of Chicago, made generally available to City the course of official City business political contribution otherwise d "none"). As to any gift listed beld»w
N/A
arty's knowledge after reasonable inquiry, the following is a Ij)isclosing Party has given or caused to be given, at any time during
the
execution date of this EDS, to an employee, or elected or appointed for purposes of this statement, a "gift" does not include: (i) anything imployees or to the general public, or (ii) food or drink provided in
and having a retail value of less than $25 per recipient, or (iii) a ily reported as required by law (if none, indicate with "N/A" or , please also list the name of the City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
that the Disclosing Party (check one)
ned in MCC Section 2-32-455(b).
2. If the Disclosing Party IS a fir ancial institution, then the'Disclosing Party pledges:
"We are not and will not become l predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. 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."
Page 7 of 15
of its affiliates (as defined in 3f MCC Chapter 2-32, explain
If the Disclosing Party is unable to make this pledge because it or any MCC Section 2-32-455(b)) is a predatory lender within the meaning here (attach additional pages if necessary):
nes above, it will be statements.
Ifthe letters "NA," the word "None," or no response appears on the 1 conclusively presumed that the Disclosing Party certified to the abovte
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
Disclosing Party's knowledge have a financial interest in his or
1. In accordance with MCC Section 2-156-110: To the best of the after reasonable inquiry, does any official or employee of the City her own name or in the name of any other person or entity in the Matlter?
QYes
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) ajid D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
permitted, no City elected rjame or in the name of any to the City, or (ii) is sold for
of the City (collectively, he City's eminent domain Part D.
s jit i
tns
2. Unless sold pursuant to a process of competitive bidding, or otherwise official or employee shall have a financial interest in his or her own other person or entity in the purchase of any property that (i) belongs taxes or assessments, or (iii) is sold by virtue of legal process at the "City Property Sale"). Compensation for property taken pursuant to power does not constitute a financial interest within the meaning of
Does the Matter involve a City Property Sale?
QYes [7]No
Nature
Name
3. If you checked "Yes" to Item D(l), provide the names and busine or employees having such financial interest and identify the nature of
Business Address
;s addresses of the City officials the financial interest:
of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial acquired by any City official or employee.
Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) must disclose below or in an attachment comply with these disclosure req connection with the Matter voidable
?elow. If the Disclosing Party checks (2), the Disclosing Party to this EDS all information required by (2). Failure to jirements may make any contract entered into with the City in by the City.
ver if i
ced
es that the Disclosing Party has searched any and all records of all predecessor entities regarding records of investments or profits policies during the slavery era (including insurance policies coverage for damage to or injury or death of their slaves), and such records.
Disclosing Party has found policies. The Disclosing Party records, including the names of
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
records of investments or profits from slavery or slaveholder insurance verifies that the following constitutes full disclosure of all such and all slaves or slaveholders described in those records:
any
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally federally funded, proceed to Sec tion the City and proceeds of debt obi igat
funded, complete this Section VI. If the Matter is not VII. For purposes of this Section VI, tax credits allocated by ions of the City are not federal funding.
A. CERTIFICATION REGARD
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amenc ed, 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 beg appear, it will be conclusively prrjs registered under the Lobbying Di behalf of the Disclosing Party wi
ns on the lines above, or if the letters "NA" or if the word "None" sumed that the Disclosing Party means that NO persons or entities ^closure Act of 1995, as amended, have made lobbying contacts on 1 h respect to the Matter.)
2. The Disclosing Party has r any person or entity listed in para person or entity to influence or at by applicable federal law, a mem Ver.2018-l'
ot spent and will not expend any federally appropriated funds to pay graph A( l) above for his or her lobbying activities or to pay any empt to influence an officer or employee of any agency, as defined )er of Congress, an officer or employee of Congress, or an employee . Page 9 of 15
funded contract, making any , or to extend, continue, renew, agreement.
of a member of Congress, in connection with the award of any feden Uy federally funded grant or loan, entering into any cooperative agreemc nt amend, or modify any federally funded contract, grant, loan, or cooperative
end of each calendar quarter in ic statements and information set
3. The Disclosing Party will submit an updated certification at the which there occurs any event that materially affects the accuracy of t forth in paragraphs A(l) and A(2) above.
described in section described in section and will not engage in "Lobbying 1995, as amended.
4. The Disclosing Party certifies that either: (i) it is not an organization 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged Activities," as that term is defined in the Lobbying Disclosure Act of
riust obtain certifications equal in Subcontractors before it awards ' certifications for the ail able to the City upon request.
5. If the Disclosing Party is the Applicant, the Disclosing Party form and substance to paragraphs A(l) through A(4) above from all any subcontract and the Disclosing Party must maintain all such subcontractors duration of the Matter and must make such certifications promptly a
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OP
Applicant and all proposed in writing at the outset of
If the Matter is federally funded, federal regulations require the subcontractors to submit the following information with their bids or negotiations.
Is the Disclosing Party the Applicant? __Yes [/jNo
If "Yes," answer the three questions below:
1. Have you developed and do you have on file affirmative action prjograms pursuant to applicable federal regulations? (See 41 CFR Part 60-2.) [/]Yes __}No
pf the Office of Federal Contract ission all reports due under the
Yes
2. Have you filed with the Joint Reporting Committee, the Director Compliance Programs, or the Equal Employment Opportunity Comrr applicable filing requirements?
| |No ?[Reports not required
3. Have you participated in any previous contracts or subcontracts subject to the
Yes
/
equal opportunity clause?
— QNo
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 of 15
SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
A. The certifications, disclosure? contract or other agreement procurement, City assistance, or of any contract or taking other it must comply with all statutes,
, and acknowledgments contained in this EDS will become part of any betwfeen the Applicant and the City in connection with the Matter, whether )ther City action, and are material inducements to the City's execution action with respect to the Matter. The Disclosing Party understands that ordinances, and regulations on which this EDS is based.
B. The City's Governmental Eth obligations on persons or entities of this ordinance and a training also be obtained from the City's (312) 744-9660. The Disclosing
cs Ordinance, MCC Chapter 2-156, imposes certain duties and seeking City contracts, work, business, or transactions. The full text program is available on line at www.cityofchicago.org/Ethics , and may if oard of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610, Party must comply fully with this ordinance.
in
C. If the City determines that an any contract or other agreement i or voidable, and the City may putsue void), at law, or in equity, includ: and/or declining to allow the law for a false statement of damages.
i information provided in this EDS is false, incomplete or inaccurate, connection with which it is submitted may be rescinded or be void any remedies under the contract or agreement (if not rescinded or ng terminating the Disclosing Party's participation in the Matter Disclosing Party to participate in other City transactions. Remedies at material fact may include incarceration and an award to the City of treble
D. It is the City's policy to make request. Some or all of the available on the Internet, in completing and signing this EDS claims which it may have against contained in this EDS and also in this EDS.
this document available to the public on its Internet site and/or upon information provided in, and appended to, this EDS may be made publicly response to a Freedom of Information Act request, or otherwise. By the Disclosing Party waives and releases any possible rights or the City in connection with the public release of information authorizes the City to verify the accuracy of any information submitted
t us
City
E. The information provided in Party must supplement this EDS contract being handled by the update this EDS as the contract 1-23, Article I (imposing information provided herein rega by MCC Chapter 1-23 and Secti
requi
EDS must be kept current. In the event of changes, the Disclosing jp to the time the City takes action on the Matter. If the Matter is a 's Department of Procurement Services, the Disclosing Party must ires. NOTE: With respect to Matters subject to MCC Chapter PERMANENT INELIGIBILITY for certain specified offenses), the
cn
ding eligibility must be kept current for a longer period, as required 2-154-020.
Page 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that this EDS, and all applicable Appendices, on behalf of the Disclosing certifications and statements contained in this EDS, and ,all applicabl and complete as of the date furnished to the City.
he/she is authorized to execute Party, and (2) warrants that all ; Appendices, are true, accurate
Sinai Health System
(Print or type exayA legal name o^0isclosing Party)
Airica Steed
(Print or type name of person signing) EVP/COO
(Print or type title of person signing)
NotaryvPublic
Commission expires:
Signed and sworn to before me on (date) at M)f^ County, IUMLS-(^.e).
\mwo
OFFICIAL SEAL" ARELLANO lie. State of Illinois Expires 11/30/2020
Page 12 ot 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
direct ownership interest in the
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a
Applicant exceeding 7.5%. It is not to be completed by any legal
entity which has only an indirect ownership interest in the Applicant.
city
Under MCC Section 2-154-0 or any "Applicable Party" or any relationship" with any elected the date this EDS is signed, the Partner thereof is related to the rr department head as spouse or adoption: parent, child, brother father-in-law, mother-in-law, son stepdaughter, stepbrother or steps ister
o
5, the Disclosing Party must disclose whether such Disclosing Party Spouse or Domestic Partner thereof currently has a "familial official or department head. A "familial relationship" exists if, as of Ejisclosing Party or any "Applicable Party" or any Spouse or Domestic ayor, any alderman, the city clerk, the city treasurer or any city dorfaestic partner or as any of the following, whether by blood or sister, aunt or uncle, niece or nephew, grandparent, grandchild, in-law, daughter-in-law, stepfather or stepmother, stepson or or half-brother or half-sister.
"Applicable Party" means (1) II.B.l.a., if the Disclosing Party i Party is a general partnership; all Disclosing Party is a limited Disclosing Party, if the Disclosing Disclosing Party; and (3) any Party. "Principal officers" means financial officer, treasurer or
all executive officers of the Disclosing Party listed in Section
a corporation; all partners of the Disclosing Party, if the Disclosing general partners and limited partners of the Disclosing Party, if the partnership; all managers, managing members and members of the
Party is a limited liability company; (2) all principal officers of the person having more than a 7.5% ownership interest in the Disclosing
the president, chief operating officer, executive director, chief secretary of a legal entity or any person exercising similar authority.
Does the Disclosing Party or currently have a "familial relatiorlsh
any "Applicable Party" or any Spouse or Domestic Partner thereof ip" with an elected city official or department head?
QYes
If yes, please identify below which such person is connected; whom such person has a familial
the name and title of such person, (2) the name of the legal entity to 3) the name and title of the elected city official or department head to relationship, and (4) the precise nature of such familial relationship.
Page 13 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AltfD AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
any legal entity which has a direct ' is not to be completed by any icant.
This Appendix is to be completed only by (a) the Applicant, and (b) ownership interest in the Applicant exceeding 7.5% (an "Owner"). ] legal entity which has only an indirect ownership interest in the App
1. Pursuant to MCC Section 2-154-010, is the Applicant or any Owfier identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
Yes
?
2. If the Applicant is a legal entity publicly traded on any exchange the Applicant identified as a building code scofflaw or problem land 2-92-416?
is any officer or director of ord pursuant to MCC Section
/ The Applicant is not publicly traded on any exchange.
3. If yes to (1) or (2) above, please identify below the name of each as a building code scofflaw or problem landlord and the address of the pertinent code violations apply.
person or legal entity identified 1 building or buildings to which
Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
E & SALARY HISTORY SCREENING - CERTIFICATION
This Appendix is to be completed defined in MCC Section 2-92-38 generally covers a party to any consideration for services, work o or (ii) pay the City money for a 1 City premises.
only by an Applicant that is completing this EDS as a "contractor" as . That section, which should be consulted (www.amlegal.com ), agreement pursuant to which they: (i) receive City of Chicago funds in r goods provided (including for legal or other professional services), icense, grant or concession allowing them to conduct a business on
On behalf of an Applicant that is the Applicant is in compliance wi job applicants based on their wag^ history from current or former includes those prohibitions.
f/jYes
QNo
[ |N/A -1 am not an Applicant tjiat is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as thfe affidavit required by MCC Section 2-92-385(c)(l).
If you checked "no" to the above,
Pane 15 of 15
Attachment A
SECTION II - DISCLOSURE Part B - Supplement
Name
Karen Teitelbaum Airica Steed Rachel Dvorken Debra Wesley Robert Markin Laurie Hernandez Albert Grace Roxanne Decyk
Title
President & Chief Executive Officer Executiv: Vice President/Chief Operating Officer Executiv: Vice President, General Counsel Executive Vice President/President of Sinai Community Institute\ Board Di ectors Officer Board Di ectors Officer Board Di ectors Officer Board Di ectors Officer
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I -¦ GENERAL INFORMATION
Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable: LAWNDALE OGDEN DEVELOPMENT LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
r~j the Applicant
OR
[|/] a legal entity currently holding, or anticipated to hold within six months after City action on the contract, transaction or other undertaking to which this EDS pertains (referred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal name: ogden Washtenaw jv llc
OR ": -
^ a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
Business address ofthe Disclosing Party: 2621 w. istn Place
Chicago, IL 60608
Telephone: (773)521-8000 pax: (773)S27-9424 Email: alex@chicagolilmstudlos.com
Name of contact person: Aiex s. Pissios
Federal Employer Identification No. (if you have one): ;
F. Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Applicant ia ooc-lting Neighborhood Opportunity Zcr;e funds to assist with tho develuumtint of a mixed uso project al West Ogden Ave. and Washtenaw Ave Cliicaijo
G. Which City agency or department is requesting this EDS? Department of Planning & Development
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification // N/A and Contract «'
Ver.2018-1 Pace 1 of 15
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature ofthe Disclosing Party^ Person
Publicly registered business coiporation Privately held business coiporation Sole proprietorship General partnership Limited partnership Trust
Limited liability company Limited liability partnership Joint venture
Not-for-profit coiporation the not-for-profit corporation also a 501(c)(3))? Yes [JNo
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
ILLINOIS
3. For legal entities not organized in the State of Illinois: Flas the organization registered to do business in the State of Illinois as a foreign entity?
? Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ol'the Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
limited liability company, or interest of a beneficiary of a (rust, estate or other similar entity. If none, state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
Lawndale Real Estate LLC 2621 W. 15th Place. Chicago, IL 60608 30%
jringthe
12-month period preceding the date of tliis EDS? /es
SECTION III INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official duringjhe
res
Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month period, following the date of this EDS? Yes
If "yes" to either of the above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
r~]Yes
Does any City elected official or, to the best ofthe Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 of the Municipal^ode of Chicago ("MCC")) in the Disclosing Party?
"I/tNo
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(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 (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom (he 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. Ifthe 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.
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.
NWoVx su)&t r.l. hi yvJ^vgc Br, Sfe TOclvic^o zl (co<^>£=>
%ko-^h- (\VrgC^l^ fzs/\wv^UA S;*P£yV§^ $ XO.OOCf
(Add sheets if necessary)
QJ Check here ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC 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?
[Q]Yes Q^No QjNo 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?
QYes 0^o
FURTHER CERTIFICATIONS
[This paragraph 1 applies only ifthe Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
!'n,\": 4 of" .15
The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(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, during the 5 years before 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; forgeiy; 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 ofthe offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before 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 Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) 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 aperson or entity that: directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").
P;iec 5 of IS
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 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during die 5 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the.provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any 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 a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither die Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] of the Applicant 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 with Article I is a continuing requirement for doing business with the City. NO I E: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR. APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their .subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant 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 Certifications (2) and (9) above and will not. without the prior written consent ofthe Cityuse any such
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. Ifthe Disclosing Party is unable to certify to any ofthe above statements in this PartB (Further Certifications), the Disclosing Partv must explain below:
m/A ; r
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all cirrrent employees of the Disclosing Party who were, at any time during the 12-month period preceding the date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
13. 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 $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list die name of the City recipient.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION 1. The Disclosing Parly certifies that the Disclosing Party (check one)
a'"financial institution" as defined in MCC Section 2-32-455(b).
2. Ifthe Disclosing Patty IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatoi y lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."
! Ver.2<)lK-!
Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessarv):
-WA- " - - —
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110; To the best of the Disclosing Party's knowledge after reasonable inquiry, 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?
QYes QJNOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and 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?
3. If you checked "Yes" to Item D(l), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (1) or (2) below. If the Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
?f 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
J [_2. The Disclosing Party verifies that, as a result of conducting the search in step (I) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: Ifthe Matter is federally funded, complete this Section VI. Ifthe 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, as amended, who have made lobbying contacts on behalf of the Disclosing Party, with respect to the Matter: (Add sheets if necessary):
. djk_. ________ :
(If no explanation appears' or begins on the lines above, or if the letters "NA" or ifthe word "None" appear, it will be conclusively presumed (hat the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995, as amended, 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
Ver.20 !S-1 Page 9 nf 15
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.
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( 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) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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
Ifthe 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?
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.)
2. Have you filed wi th 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?
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 ol" 15
SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees'that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www. city of Chicago. 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 this ordinance.
Ifthe 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 City transactions. 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 in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department, of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect, to Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
P.-ific 11 oJ 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS. and all .applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate and complete as ofthe date furnished to the City.
(Print or type exact \cml name of Disclosing Party)
(Sign here
(Print or type name of person signing)
_tLr_Cil=r ;
(Print or l^pfijtitle of person signing)
Notary Public
Signed and sworn to before me on (date) /^/^B^/ ^ at /sfr&fc— County, /^/ft^state).
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%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC 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 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 the Disclosing Party listed in Section II.B. 1 .a., ifthe 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 of the Disclosing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5% 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?
If yes, please identify below (I) the name and title of such person, (2) die 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.
[';;;...• 13 of 15
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 (It) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (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 MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
2. Ifthe 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 MCC Section 2-92-416?
3. If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
I'age 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING ¦ CERTIFICATION
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted ("www.amlegal.comV generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-3 85(b)(1) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers, 1 also certify that the Applicant has adopted a policy that includes those prohibitions.
QYes QNo
This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l).
If you checked "no" to the above, please explain.
Pai.'.e 1.5 n!'J5
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
r OR
2. a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: CKitfru ^teVMtAAsQjjj U__
OR O
3. [ ] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party: TJtflA. \j0 1^7^* P(#<-^
Telephone: 773 ' f)U 'ffiPO Fax: -p*yfo(- foW Email: a\*H Q cWtOZp t\ fVl
Name of contact person: ^V^Federal Employer Identification No. (if you have one): _
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable):
Which City agency or department is requesting this EDS? _) f ^)
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # _ and Contract #
Ver.2018-1 Page 1 of!5
SECTION TI DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing
[ ] Person
[ ] Publicly registered business corporation
[ ] Privately held business corporation
[ ] Sole proprietorship
[ ] General partnership
[ ] Limited partnership
[ ] Trust
[vf Limited liability company
[ ] Limited liability partnership
[ ] Joint venture
[ ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ] Yes [ ] No [ ] Other (please specify)
For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
X.\)v,_y,*=_ :
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 [vft5rganized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
J\W fission Mamy<~
2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest of a member or manager in a
Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None." . , .
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
ftW^ ?if>5.<_?^ yAj \i?_U- Pitto*) 5\/_^l uj Pt fVxaxgSL- 4
Pi^g6 uj If. f< sVlCasfi 4
SECTION III -- INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? [yjYes [ ] No
Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month period following the date of this EDS? [ ] Yes [vf-fJo
If "yes" to either ofthe above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 ofthe MunicipalC^de of Chicago ("MCC")) in the Disclosing Party? [ ] Yes [vfNo
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(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 (as defined in MCC Chapter 2-156), 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. Ifthe 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 15
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.
rAucK sla,Wr ¥.C, yjj_>Mer O. S¥> A&O d*\6a^> XL foboC
(Add sheets if necessary)
[ ] Check here ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V-¦ CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC 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.
Lias 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 [v^fN*o [ ] 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
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of 15
The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(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, during the 5 years before 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 subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before 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 Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) 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 ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Parly, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of 15
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 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 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 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 subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or ofthe United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] ofthe Applicant 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 MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant 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 Certifications (2) and (9) above and will not, without the prior written consent ofthe City, use any such
Ver.2018-1 Page 6 of 15
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. Ifthe Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. 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 date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
13. 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, 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 clrink provided in the course of official City business and having a retail value of less than $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (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 [v'Tts not
a "financial institution" as defined in MCC Section 2-32-455(b).
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 MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. 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 15
Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-.455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
tOp .
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 FINANCIAL IN TEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, 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 [v^o
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), skip Items D(2) and D(3) and 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 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 [vfNo
If you checked "Yes" to Item D(l), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature of the financial interest:
Name Business Address Nature of Financial Interest
4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.
Page 8 of 15
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 (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.
A1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits ' from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI -- CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
$4h
(If no explanation appears or begins on the lines above, or ifthe 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, as amended, 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 liinds 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
Ver.2018-1 Page 9 of IS
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.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
Ifthe 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 Appjjcant? [ ] Yes [VlNo
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed, with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No [ ] Reports not required
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 15
SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance 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 this ordinance.
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 City transactions. 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 in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. Ifthe 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 MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
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CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate and complete as of the date furnished to the City.
LOT.w\A.l_t. fexA . LLC,
(Print or type qxact legal name of Disclosing Party)
By:
(STgnhb?e7 (Print or type name of person signing)
fc_____k__y_C
(Print or typ& title of person signing)
Signed and sworn to before me on (date) /(^/ at f^&Q^ County,\J^//?D/S (state).
- rr - — _____
KAREN A BANKS FRITCHEY Official Seal Notary Public - State of Illinois My Commission Expires Aug 15,2020
Commission expires:
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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%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC 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 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 ofthe Disclosing Party listed in Section ILB.l.a., 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, ifthe Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5% 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) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
[ ] Yes [^fNo
Ifthe 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 MCC Section 2-92-416?
[ ] Yes [ ] No [vfTTie Applicant is not publicly traded on any exchange.
3. If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
i
This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted rwww.amlegal.com ), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on City premises.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
[ ] Yes
[]No
[vfN/A -1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l). If you checked "no" to the above, please explain.
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