OFFICE OF THE MAYOR
CITY OF CHICAGO
LORI E. LIGHTFOOT
MAYOR
July 24, 2019
TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO
Ladies and Gentlemen:
At the request of the Commissioner of Transportation^ I transmit herewith an ordinance authorizing acquisition of property on portions of West Clarence Avenue.
Your favorable consideration of this ordinance will be appreciated.
Very truly yours,
I
ORDINANCE
WHEREAS, The City of Chicago (the "City") is a home rule unit of government pursuant to Article VII, Section 6(a) of the 1970 State of Illinois Constitution and may exercise any power related to its local governmental affairs; and
WHEREAS, Pursuant to an ordinance adopted on April 15, 2015 ("Acquisition Ordinance") and published at pages 106338 through 106340, in the Journal of such date, the City Council approved the acquisition by the Commissioner ("Commissioner") of the City's Department of Transportation ("CDOT") of portions of the real property commonly known as 7733-7759 West Clarence Avenue, Chicago, legally described on Exhibit A thereto ("Parcels") for right of way purposes, vehicular access by the public and emergency responders and any other public purpose; and
WHEREAS, The Acquisition Ordinance authorized the Corporation Counsel to undertake negotiations on behalf of the City with the owners of the Parcels; and
WHEREAS, Such negotiations have proceeded and the City has reached agreement with Brian Healy and Bridget Healy, a married couple and Healy & McMahon, LLC, a dissolved Illinois limited liability company, the owners of the Parcels (collectively and jointly and severally, "Seller") on a purchase price of $88,000.00 ("Purchase Price") for the portion of the Parcels legally described on Exhibit A hereto and depicted on Exhibit B hereto ("Property"), which is conditioned on the parties entering into a purchase agreement in substantially the form attached hereto as Exhibit C ("Purchase Agreement"); and
WHEREAS, The Acquisition Ordinance authorized the Commissioner or a designee of the Commissioner to execute the documentation necessary to acquire all or any portion of the Parcels, including the Property, subject to the approval of the Corporation Counsel and subject to the approval of the purchase price by the City Council pursuant to a separate ordinance; now, therefore,
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1. The recitals set forth above are incorporated herein by reference and made a part hereof.
SECTION 2. The City hereby approves the acquisition of the Property by the City from Seller for the Purchase Price, subject to the availability of appropriated funds and to Seller and the City entering into the Purchase Agreement.
SECTION 3. If any provision of this ordinance shall be held to be invalid or unenforceable for any reason, the invalidity or unenforceability of such provision shall not affect any of the other provisions of this ordinance.
SECTION 4. All ordinances, resolutions, motions or orders in conflict with this ordinance are hereby repealed to the extent of such conflict.
SECTION 5. This ordinance shall be effective upon its passage and approval.
Attachments:
Exhibit A - Legal Description of the Property Exhibit B - Depiction of the Property Exhibit C - Form of Purchase Agreement
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EXHIBIT A
Legal Description of Property
(Subject to Final Survey and Title Commitment)
THE WEST 80.00 FEET OF THE EAST 276.00 FEET, AS MEASURED ALONG THE NORTH AND SOUTH LINES THEREOF, AND THE NORTH 9.00 FEET (MEASURED PARALLEL WITH THE NORTH LINE THEREOF) OF THE EAST 196.00 FEET, AS MEASURED ALONG THE NORTH AND SOUTH LINES THEREOF, OF THE SOUTH 53.07 FEET OF THAT PART OF THE NORTHWEST 1/4 OF SECTION 1, TOWNSHIP 40 NORTH, RANGE 12, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS, THAT IS DESCRIBED AS FOLLOWS:
BEGINNING AT A POINT IN A LINE DRAWN PARALLEL WITH AND 993.49 FEET WEST OF THE EAST LINE OF SAID NORTHWEST 1/4 AS MEASURED PARALLEL WITH THE NORTH LINE THEREOF, 972.75 FEET SOUTH OF THE NORTH LINE OF SAID NORTHWEST 1/4 AS MEASURED ALONG SAID PARALLEL LINE; THENCE SOUTH PARALLEL WITH THE EAST LINE OF SAID NORTHWEST 1/4 , 93.07 FEET; THENCE WEST PARALLEL WITH THE NORTH LINE OF SAID NORTHWEST 1/4 , 453.60 FEET TO THE CENTER LINE OF CANFIELD ROAD; THENCE NORTHEASTERLY ALONG THE CENTER LINE OF CANFIELD ROAD TO A LINE DRAWN THROUGH SAID POINT OF COMMENCEMENT AND PARALLEL TO THE NORTH LINE OF SAID NORTHWEST 1/4; THENCE EAST PARALLEL WITH THE NORTH LINE OF SAID NORTHWEST 1/4 TO THE POINT OF BEGINNING.
PINs: 12-01-105-089-0000 (Part of) 12-01-105-090-0000 (Part of)
Commonly known as: 7733-7759 West Clarence Avenue, Chicago, IL
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EXHIBIT B Depiction of Property See following page.
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B-2
EXHIBIT C
Form of Agreement of Purchase and Sale
THIS AGREEMENT OF PURCHASE AND SALE ("Agreement") having an Effective
Date of , 2019, is entered into by and between
("Seller") and the CITY OF CHICAGO, a municipal corporation organized and existing under and by virtue of the laws of the State of Illinois ("Buyer").
RECITALS:
A. The contact information of the parties to this Agreement is as follows.
SELLER: BUYER:
City of Chicago
Department of Transportation
Attn:
Chicago, Illinois 60602
Tel:
With a copy to: With a copy to:
City of Chicago
Department Of Law
Attn:-
121 N. LaSalle Street, Room 600
Chicago, Illinois 60602
Tel:
Seller is the owner of real property located in Cook County, Illinois as legally described in Exhibit A and depicted in Exhibit B attached hereto and incorporated herein by this reference. Said real property, together with any and all buildings, improvements, fixtures, timber, water and/or minerals located thereon and any and all rights appurtenant thereto, shall be referred to in this Agreement as the "Property" or "Subject Property."
Buyer wishes to acquire the Property from Seller in accordance with the terms and conditions set forth in this Agreement for right of way purposes, including the widening of a portion of Clarence Avenue and improved vehicular access by the public and emergency responders.
NOW THEREFORE, THE PARTIES AGREE AS FOLLOWS:
1. Purchase and Sale. For Ten and 00/100 Dollars ($10.00) and other good and valuable consideration, receipt and sufficiency which are hereby acknowledged, Seller agrees to
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sell to Buyer and Buyer agrees to buy from Seller the Property on the terms and conditions set forth herein.
Purchase Terms.
Price. The purchase price (the "Purchase Price") for the Subject Property shall be EIGHTY EIGHT THOUSAND AND NO/100 DOLLARS ($88,000.00).
Method of Payment. The Purchase Price shall be payable in cash, at Closing (as defined below), subject to any credits, pro-rations and adjustments provided in this Agreement.
Closing Conditions Related to the Subject Property.
Prior to Closing and as conditions to Closing, Buyer shall:
Make an independent investigation of the physical condition of the Subject Property including but not limited to the condition of the soil, the presence of hazardous materials or contaminants, other physical characteristics, and compliance with any statutes, ordinances or regulations;
Study all aspects or circumstances of the Subject Property which Buyer deems material or relevant;
Receive from Seller all documents and materials, which Buyer deems material or relevant with respect to the transaction contemplated under this Agreement;
Have had full, complete and satisfactory access to the Subject Property, and all records relating to the same, which Buyer has requested and/or deemed material or relevant; and
Have had the opportunity to make all inspections and verifications, which Buyer deemed necessary for the completion of Buyer's due diligence review for the transactions covered by this Agreement.
Prior to Closing and as conditions to Closing, Seller shall:
Terminate any leases, including but not limited to any parking lease, on the Property; and
Remove all personal property from the Property.
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(c) Buyer agrees that:
Buyer shall not rely on any representations or warranties made by Seller with respect to the Subject Property except as set forth in this Agreement;
Seller shall not be responsible for any statements, representations or warranties of any kind furnished to Buyer by any real estate broker or any other person, unless the same are specifically set forth in this Agreement; and
No materials, brochures, or documents delivered by Seller to Buyer or any other person shall be, or be deemed, a representation, warranty, or agreement of Seller under, or with respect to, this Agreement; and Buyer has, and shall have, the exclusive responsibility for verifying any facts or conditions set forth or described in any such materials, brochures or documents.
(d) Subsequent to the fulfillment of the closing conditions set forth above in Section 3(a), Buyer agrees to accept the Subject Property "as is, where is" in its present condition with all faults and condition having had the opportunity to perform a thorough evaluation of the condition of the Property and/or as otherwise required pursuant to the terms of this Agreement, subject to all reasonable use and wear and tear of, or to, the Subject Property. Seller makes no warranty, either express or implied, as to the physical or environmental condition of the Property, or its fitness for a particular purpose.
Closing. Final settlement of the obligations of the parties hereto (the "Closing") shall occur no later than thirty (30) days following the Effective Date, or such later date as determined by Buyer at Buyer's sole discretion. Closing shall occur at Greater Illinois Title Company, as agent for Chicago Title Insurance Company, 120 N. LaSalle St., 9th Floor, Chicago, Illinois (the "Escrow Holder") at such time as the parties shall agree. This sale shall be closed through a "New York style" closing procedure with the Escrow Holder. The cost of the closing procedure shall be divided equally between Seller and Buyer in accordance with the customary practice of Cook County, Illinois. Seller (if required) will execute a gap undertaking in the form required by the title insurer in order to close by a "New York style" closing.
Title. Seller shall by warranty deed convey to Buyer its interest in the Subject Property subject to the following:
any federal, state or local laws, ordinances, regulations and/or orders
whatsoever;
liens for real estate taxes not yet due and payable and other taxes and
assessments of any kind or nature assessed (not yet due and payable) with respect to the
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Property;
levied and pending special assessments;
the standard printed exceptions on the form of title commitment other than those which Escrow Holder agrees to remove upon the delivery by Seller of a customary ALTA Statement; and
(e) acts done or suffered by the Buyer, or anyone claiming, by, through or
under Buyer.
Title Insurance. Buyer may at its option and its sole cost and expense procure an owner's policy of title insurance from Escrow Holder insuring that title to the Property is vested in Buyer upon Closing.
Seller's Promise not to Further Encumber. Seller shall not, without the prior written consent of Buyer, make any leases, contracts, options or agreements whatsoever affecting the Property which would in any manner impede Seller's ability to perform hereunder and deliver title as agreed herein.
Seller's Representations. Seller makes the following representations:
Seller has the power to sell, transfer and convey all right, title and interest in and to the Property.
Seller represents and warrants that it is not a "foreign person" as defined in Section 1445 of the Internal Revenue Code.
Prorations, Closing Expenses and Fees. The following costs will be prorated and due and payable at Closing. Seller is responsible for all real estate taxes and assessments, which accrued during the period the Property was owned by Seller. At Closing, Buyer will assume responsibility for all real estate taxes and assessments, which accrue on the date of the Closing and thereafter. Buyer is entitled to claim an exemption for all stamp taxes imposed by State, County and City law or ordinance on the transfer of the title to the Property. Buyer agrees to claim and substantiate all such exemptions at Closing. If required to accomplish such exemption, Seller agrees to provide a City transfer declaration at Closing. If prior to Closing the applicable law or ordinance is changed in a manner that denies Buyer any such exemption from stamp tax, then said stamp tax shall be paid in accordance with the customary practice of Cook County, Illinois. Buyer shall pay the premium for any title insurance policy. All recording fees and all other fees and charges not otherwise allocated in this Agreement shall be allocated in accordance with the customary practice of Cook County, Illinois.
Notices. All notices pertaining to this Agreement shall be in writing delivered to the parties hereto personally by hand, overnight courier, or by first class mail, postage prepaid,
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return receipt requested at the addresses set forth in Recital A. All notices shall be deemed given when deposited in the mail, first class postage prepaid, return receipt requested, addressed to the party to be notified; or if delivered by hand or overnight courier service, shall be deemed given when delivered. The parties may, by notice as provided above, designate a different address to which notice shall be given.
Remedies Upon Default. In the event either party defaults in the performance of any of their respective obligations under this Agreement, the non-defaulting party shall, in addition to any and all other remedies provided in this Agreement or by law or equity, have the right of specific performance against the defaulting party.
No Broker's Commission. Each party represents to the other that it has not used a real estate broker in connection with this Agreement or the transaction contemplated by this Agreement. In the event any person asserts a claim for a broker's commission or finder's fee against one of the parties to this Agreement, the party on account of whose conduct the claim is asserted will hold the other party harmless from said claim.
Time of the Essence. Time is of the essence of this Agreement.
Binding on Successors. This Agreement shall be binding not only upon the parties but also upon their assigns (as permitted under Section 16) and other successors in interest.
Additional Documents. Seller and Buyer agree to execute such additional documents, including escrow instructions, as may be reasonable and necessary to carry out the provisions of this Agreement.
Assignment. Neither party may assign its interests under this Agreement without the written consent of the other party.
Entire Agreement: Modification; Waiver. This Agreement constitutes the entire agreement between Buyer and Seller pertaining to the subject matter contained in it and supersedes all prior and contemporaneous agreements, representations, and understandings. No supplement, modification or amendment of this Agreement shall be binding unless executed in writing by all the parties. No waiver of any of the provisions of this Agreement shall be deemed or shall constitute a waiver of any other provision, whether or not similar, nor shall any waiver constitute a continuing waiver. No waiver shall be binding unless executed in writing by the party making the waiver.
Counterparts. This Agreement may be executed electronically and in counterparts, each of which shall be deemed an original and which together shall constitute one and the same agreement.
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Severability. Each provision of this Agreement is severable from any and all other provisions of this Agreement. If any provision(s) of this Agreement is for any reason unenforceable, the balance shall nonetheless be of full force and effect.
Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Illinois.
Acceptance of Deed. The delivery by Seller and acceptance by Buyer of the deed shall be deemed to be full performance by Seller and Buyer of, and shall discharge Seller and Buyer from, all obligations hereunder and Seller and Buyer shall have no further liability hereunder, except for obligations and liabilities which expressly survive closing as set forth herein.
Possession. Seller shall deliver possession of the Property to Buyer concurrently with Closing in accordance with Sections 3 and 5.
Buyer's Representation. Buyer represents that it has full power and authority to enter into this Agreement and the person signing this Agreement for Buyer has full power and authority to sign for Buyer and to bind it to this Agreement.
Miscellaneous. In the event that any of the deadlines set forth herein end on a Saturday, Sunday or legal holiday, such deadline shall automatically be extended to the next business day which is not a Saturday, Sunday or legal holiday. The term "business days" as may be used herein shall mean all days which are not on a Saturday, Sunday or legal holiday.
(Signature Page Follows)
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IN WITNESS of the foregoing provisions the parties have executed and delivered this Agreement as of the Effective Date.
SELLER:
THE CITY OF CHICAGO, a municipal corporation organized and existing under and by virtue of the laws of the State of Illinois
Name: Brian Healy
HEALY & McMAHON, LLC, a dissolved Illinois company
By:_ Name: Title:
Approved as to legal form:
By:_ Name: Title:
EXHIBIT A Legal Description
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EXHIBIT B Depiction of Property
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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/b/a/ if applicable:
ftpinfiEr tt&iuj ,
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. 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.1 State the Applicant's legal
name: j
OR |
[ ] a legal entity with a direct or indirect right of control of the Applicant (see Section II(B)( 1))
State the legal name of the entity in which the Disclosing Party holds a right of control:
I
Business address of the Disclosing Party: 'TfStflS IaJ - f^lfliKriC r\jP
Telephone: Fax: Email; br'Afje}. iYlCtyain/rnheaL j
Name of contact person: ;
Federal Employer Identification No. (if you have one): N jp^
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? (j £}@
If the Matter is a contract being handled by the City's Department of Procurement: Services, please complete the following: j
Specification # and Contract # j
Ver.20l8-l Page I of 15
- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
^Person [ ] Limited liability company
[ ] Publicly registered business corporation [ ] Limited liability partnership
[ ] Privately held business corporation [ ] Joint venture |
[ ] Sole proprietorship [ ] Not-for-profit corporation
[ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))?
[ ] Limited partnership [ ] Yes [ ] No
[ ] Trust [ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
[ 1 Yes [ ] No [ ] Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
I. 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. |
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NOTE: Each legal entity listed below must submit an EDS on its own behalf
Name Title i
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
Ver.2018-1 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
Percentage Interest in the Applicant
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? | [ ] Yes p(\ 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 .^vfNo
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 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party? [ ] Yes - J>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 eachisubcontractor, 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. 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. i
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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.) j "hourly rate" or "t.b.d." is
not an acceptable response.
fliKl Surv^inj S8ft W /%j\nS He Ch\Ch3 p «Smrw^nr 1 3 3500 ^_
fttSfrjftfrj ,ar. 1Aft ^ ftAarlisoo . chjrng n fytry rflpj- dflppo
(Add sheets if necessary) /S&mnCtf-I V--P- BonkS fttbvT\<£f J^fcO PrVfp^
/ppVerCT SoulaxdtS rVpnaiStrr ^)c2^Dr^WD 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?
i
[ ] Yes p>^No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[ ] Yes [ ] No
FURTHER CERTIFICATIONS !
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[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).
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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 ofl5
Retained | Yes | Yes | Yes | Yes | Yes |
Paid Yes No ON Yes Yes
Fees $ 3,500.00 $ 20,000.00 $ 10,000.00 $ 6,500.00 $ 1,200.00
Relationship Surveyor Architect Attorney Attorney Appraiser
Business Address 5812 W. Higgins Ave, Chicago, IL 120 W. Madison St., Chicago, IL 321 N. Clark Street, Suite 2450, Chicago, IL 221 N. Lasalle Street, #3800, Chicago, IL | 180 N. LaSalle Street, Chicago, IL
| Name |M&M Surveying |MC& Associates, LLC |Foran, OToole & Burke, LLC |Samuel V.P. Banks |Peter J. Soukoulis
The Disclosing Party and, if the Disclosing Party is a legal entity, alliof those persons or entities identified in Section II(B)( 1) of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded from any transactions by any federal, state or local unit of government;
j
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;jembezzlement; 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 ajctions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government. j
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 thejDisclosing 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, ojr, with the Contractor, is under common control of another person or entity; j
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents"). |
Page 5 of 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 of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in tliat 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
i
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).
aced under supervision for,
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 of1720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense bf 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] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or p
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 "sisljer 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.
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[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 tshe 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
Ver.2018-1 Page 6 of 15
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contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications. I
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: j
0£ I : ¦
If the letters "NA," the word "None," or no response appears on the linesiabove, it will be conclusively presumed that the Disclosing Party certified to the above statements.
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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 C ity of Chicago (if none, indicate with "N/A" or "none").
wft I ,
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 ^e 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 recipients
i
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION |
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is E><3fis 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 leader may result in the loss of the privilege of doing business \yith the City."
Ver.2018-1 Page 7 of 15
If the 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 (aj^n additional pages if necessary):
If the letters "NA," the word "None," or no response appears on the lines a!bove, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
i
I
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITYiBUSINESS
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? S
[ ] Yes J><£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.
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 I JNo
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
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.
The Disclosing Party verifies that the Disclosing Party has searched any and all records of
the Dis
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
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 fulljdisclosure 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
I i
NOTE: If the Matter is federally funded, complete this Section VI. Ifjthe Matter is not federally funded, proceed to Section VII. For purposes of this Section \fl, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
i
1. List below the names of all persons or entities registered under thejfederal 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): i
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.) j
j
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( 1) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
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.
3. \he 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 infonnation set
forth in paragraphs A( 1) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged andjwill not engage in "Lobbying Activities," as that terfcn 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? [ ] Yes [ ] No
If "Yes," answer the three questions below: Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.) [ ] Yes [ ] No Have you filed with the Joint Reporting Committee, the E)irector of the Office of Federal Contract Compliance Programs, or the Equal Employment OpportunityNCommission all reports due under the applicable filing requirements? [ ] Yes [ ] No [ ] Reports not requiredHave you participated in any previous contracts or subcontracts sVbject to the equal opportunity clause? [ ] Yes [ ] No \ !
If you checked "No" to question (I) 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 Dis'closing 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.cityofchicagd.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, incornplete 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 ah award to the City of treble damages. ¦
It is the City's policy to make this document available to the public onjits 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. j
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
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.
(Print or type exact legal name of Disclosing Party)
By: ffiaW findfr
(Sign hefe) Q
(Print or type name of person signing)
QwJlv)F,£
(date! AJV) 8*, (jO \C_ County, J^))/>1& ^ (state).
Notary Public y w
(Print or type title of person signing)
Signed and sworn to before me on
OFFICIAL SEAL CATHERINE BRASZER
Notary Public' ^ W \ NOTARY PUBLIC, STATE OF ILLINOIS
My Commission Expires May 25,2020
Commission expires: 5 \2~5 /z-l -2-0
l
Page HoHS
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS j
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., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of; the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% 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) ithe 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 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFF LA W/PRO B L E M 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 riot to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
i
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? j
[ ]Yes K(No j
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 pursuantito MCC Section 2-92-416?
[ ] Yes [ ] No ^p«^The Applicant is not publicily traded pn 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.
Page 14 of 15
CITY OF CHICAGO j 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 consul'ted (ww'w.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. , 1
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On behalf of an Applicant that is a contractor pursuant to MCC Section 2[-92-385,;I 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 j [ ]No '
- 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).
i
If you checked "no" to the above, please explain.
Page IS of 15
CITY OF CHICAGO | ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT i
SECTION I - GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b'/a/ if applicable:
Check ONE of the following three boxes: j
j
Indicate whether the Disclosing Party submitting this EDS is: I
"M 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 preferred to below as the "Matter"), a direct or indirect interest in excess of 7.5% in the Applicant.! State the Applicant's legal name:
icant (see Section 11(B)(1)) of control:
OR
Appl
right
3. [ ] a legal entity with a direct or indirect right of control of the State the legal name of the entity in which the Disclosing Party holds a ri
B. Business address of the Disclosing Party: I'nirfp V\/. Pfllfltlrlt0 /W7
Telephone:
Name of contact person:
E. Federal Employer Identification No. (if you have one): n/a
Brief description of the Matter to which this EDS pertains. (Include project number and location of property, if applicable): ;
Tfrl sa\?, fit- (tf^hon of 1133- to ftlflrtft 0& NH +t) -The' C I rjj Of 0^ | cqCjO
Which City agency or department is requesting this EDS? Xl/OC11
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following: ';
Specification # Ver.2018-1
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party: j
^Person [ ] Limited liability company
] Publicly registered business corporation [ ] Limited liability partnership
] Privately held business corporation [ ] Joint venture j
] Sole proprietorship [ ] Not-for-profit corporation
] General partnership (Is the not-for-profit corporation also a 501(c)(3))?
] Limited partnership [ ] Yes [ ] No
] Trust [ ] Other (please specif^)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
!
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity? 1
[ ] Yes [ ] No [ ] Organized in Illinois I
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY: A*
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 ljegal entity that directly or indirectly controls the day-to-day management of the Applicant. j
i
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% 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 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.
I
Name Business Address Percentage Interest in the Applicant
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS i
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? ! [ ] Yes f^No
i
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 |*^No
i
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 knojwledge 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 -^No ;
If "yes," please identify below the name(s) of such City elected official(s)j and/or spouse(s)/domestic partners) 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 eachj 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 jwith 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. 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. i
Page 3 of 15
M Piong st< attend fact ^ ClM^CatTCm
Name (indicate whether Business retained or anticipated Address 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.
00
(Add sheets if necessary)
»ftm*e 1 v • P. tBqriH^ ft Htjoi fry ti-i j^Ccheck 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 competjent jurisdiction?
[ ] Yes ^^No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
[ ] 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 th'eir business practices so they can be considered for agency contracts in the future, or continue with a contract inj progress).
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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 IS
Retained | Yes | Yes | Yes | Yes | Yes |
Paid Yes No ON Yes Yes
Fees S 3,500.00 $ 20,000.00 $ 10,000.00 $ 6,500.00 $ 1,200.00
Relationship Surveyor Architect Attorney Attorney Appraiser
Business Address 5812 W. Higgins Ave, Chicago, IL 120 W. Madison St., Chicago, IL 321 N. Clark Street, Suite 2450, Chicago, IL 221 N. Lasalle Street, #3800, Chicago, IL 180 N. LaSalle Street, Chicago, IL
| Name |M&M Surveying |MC & Associates, LLC |Foran, OToole & Burke, LLC |Samuel V.P. Banks |Peter J. Soukoulis
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;
i
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 1
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 governrnjent, any state, or any other unit of local government. i
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics). j
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 Jor 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, orj with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Ver.2018-1 Page5or'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 A ffiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity; j
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 bijdders 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 (I) 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] 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 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"). i
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 form and substance to those in
Certifications (2) and (9) above and will not, without the prior wri tten conisent of the 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. j
j?
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:
hL& !
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.
i
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").
aft !
i
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 b'e 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 (iii) 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.
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION j
The Disclosing Party certifies that the Disclosing Party (check one) :
[ ] is "Wis 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:
i
"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."
Ver.2018-1 Page 7 of 15
If the 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):
: m ;
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.
In accordance with MCC Section 2-156-1 10: 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? i
[ ] Yes T>fNo
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D( 1), 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 namejor 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 flNo
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:
i
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. |
Ver.2018-1 Page Sot* 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either (I) or (2) below. If the Disclosing Party checks (2:), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (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. j
1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or djeath of their slaves), and the Disclosing Party has found no such records.
2. The Disclosing Party verifies that, as a result of conducting the search in step (I) above, the
Disclosing Party has found records of investments or profits from slavery lor 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): j
(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means tjhat 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(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 Paee9ofl5
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.
3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A( 1) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 199S, as amended.
i
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.
i
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
Is the Disclosing Party the Applicant?
[ ] Yes [ ] No
If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant 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
i
The Disclosing Party understands and agrees that:
i
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 Disblosing 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.citvofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with 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.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services!, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters' subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
a longer period, as required
information provided herein regarding eligibility must be kept current for by MCC Chapter 1-23 and Section 2-154-020.
Page 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (I) 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 taie, accurate and complete as of the date furnished to the City. i
(Print or type exact legakwame of Disclosing Party)
By: J^jfa^
Brian Hsfll
(Sign here)
r^i
Brian Wfa
(Print or type name of person signing)
cvtfmr
(Print or type title of person signing)
f
at _ County, (state).
Notary Public Commission expires: S"
Page 12 of 15
CITY OF CHICAGO j ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS j
This Appendix is to be completed only by (a) the Applicant, and (b) alny 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!
j
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 curtjently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following! whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of (the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5% 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 orj Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?
[ ]Yes b
If yes, please identify below (I) the name and title of such person, (2) which such person is connected; (3) the name and title of the elected city
the name of the legal entity to official or department head to
Ver.2018-1 Page 13 of 15
CITY OF CHICAGO j ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORDjCERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any l'egal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is nbt to be completed by any
legal entity which has only an indirect ownership interest in the Applicant.
j
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? i
[ ]Yes
I
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?
[ ] No ^L^fhe 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
APPENDIXC
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 21-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(l) and (2)J, 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
[ 3No
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
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:
Hmlti i IKCMahtm, LL.Q. \
Check ONE of the following three boxes: ;
Indicate whether the Disclosing Party submitting this EDS is: !
1. the Applicant I
OR j
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: __
OR |
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:
I
Business address of the Disclosing Party: Q\)X) Mfl^\h(9l 11 ,B1\/gI
Telephone: (TO^l ft Si 4 Fax: M^f, Email:! bflfln.\\Pa\xj fi^Name of contact person: Bflflr) ^Ptflij
E. 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): i
The 6a\t of apoftdry of TM-T&\ *)¦ Hio^ads t? rhd Qtyof-GlrwaLcjo.
Which City agency or department is requesting this EDS? C b>OT~
i'
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # and Contract #
Ver.2018-1 Paget of 15 '
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
] Person
] Publicly registered business corporation ] Privately held business corporation ] Sole proprietorship ] General partnership ] Limited partnership ] Trust
£xf Limited liability company [ ] Limited liability partnership
[ ] Joint venture '
i
[ ] Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ ]Yes [ ]Njo [ ] Other (please specify)i
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity? j
[ ] Yes . Ao
B. IF THE DISCLOSING PARTY TS A LEGAL ENTITY
I. 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. j
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
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
Pa«e 2 of 15
j
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.
¦MPto&t set^ a touted-&c
Name Business Address Percentage Interest in the Applicant
^ mpn^ti geptfmbfir aoi^ - all )nurf.u- hp id in tw>J<;L.(V wn.s irons fierrticl
tt) Tin? rV/rn Ivj <; /ft that -hme rifnhj i (UCfvinVi/^n ^ir, "> < r>/TvO /iifflfded Prla^ ft€aU iSuSto. PcilaHf\efVe
SECTION HT - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS !
i
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? [ ] Yes ^| 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 txjfNo
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 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party? [ ] Yes j>^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
i j
The Disclosing Party must disclose the name and business address of eaclk 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. 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
Percentage Interest |
Title Member Member
Business Address 2110 S. Marshall Blvd, Chicago, IL 60623 7565 W. Palatine Ave., Chicago, IL 60631
Name Frank J. McMahon Brian C. Healy
|DATE | 3/21/2011 | 3/21/2011
Percentage Interest | sp O
Title Member Member
Business Address 2110 S. Marshall Blvd., Chicago, IL 60623 7565 W. Palatine Ave., Chicago, IL 60631 7565 W. Palatine Ave., Chicago, IL 60631
Name Frank J. McMahon (Deceased) Brian C. Healy Bridget McMahon Healy
|DATE | 9/16/2012 | 9/16/2012 | 9/16/2012
Name (indicate whether Business Relationship to Disclosing Party Fees ( indicate whether
•retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) ; "hourly rate" or "t.b.d." is
not an acceptable response.
(Add sheets if necessary)
^>Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
j
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?
[ ]Yes >fNo [ ]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 jentity 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, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II(B)( 1) of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, 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 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 ojf 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, of, with the Contractor, is under common control of another person or entity; j
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents"). i
Page 5 ot" 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: i
j
a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency 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; ;
party to any such agreement,
b. agreed or colluded with other bidders or prospective bidders, or been a
otherwise; or
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
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 j
|
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 (I) 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.
j
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 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.
i
[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").
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 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
Ver.2018-1 Page 6 of 15 j
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contractor/subcontractor that does not provide such certifications or that tile Applicant has reason to believe has not provided or cannot provide truthful certifications. !|1010|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/fr-
If the letters "NA," the word "None," or no response appears on the lines aibove, 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, 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 (iij 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.
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C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is "^('s 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."
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If the 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 MtC Chapter 2-32, explain here (attach additional pages if necessary):
Silk.
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
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 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? j
>NOTE: If you checked "Yes" to Item D( 1), 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 lor in the name of any other persenor entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessfnente, or (iii) is sold by virtue of legal process at the suit o^the City (collectively, "City Property Sale^>Compensation for property taken pursuant to the City's eminent domain power does not constitutealSnancial interest within the meaning of this Part D.
Does the Matter involve a City Property!
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. 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. j
1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the1 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
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^ If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING i
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 lettefs."N|A" 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 federal y 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.2018-1 Pat-e9ofi5
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, of 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 organizatioh described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and \yill not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
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If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A( 1) 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. j
i
Is the Disclosing Party the Applicant? j
[ ] Yes [ ] No i
If "Yes," answer the three questions below: j
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 the1 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? j
[ ] Yes [ ] No I
j
If you checked "No" to question (1) or (2) above, please provide an explanation:
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SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
j
The certifications, disclosures, and acknowledgments contained in thisjEDS 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
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, of transactions. The full text of this ordinance and a training program is available on line at www.citvofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with 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. j
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 relbase 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.
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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) wan-ants 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. j
(Print or type exact legal name of Disclosing Party)
€3^
SOTl:
(Print or type name of perspri signing) (Print or type title of person signing)
County, ^ (state).
Signed and sworn to before me on (date) * lfr(iy &^/
at {0>tL — 4 . JJ
Notary Public Commission expires:
OFFICIAL SEAL '< CATHERINE GRASZER
I' lTARY PUBLiC, STATE OF ILLINOIS -mission Expires May 25, 2020
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CITY OF CHICAGO j ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A j
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) aiiy 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 "familia'l 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. j
i
"Applicable Party" means (I) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2)J 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 of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/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?
[ ]Yes
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416? !
[ 1 No ^jp^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.
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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.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.
i
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),j 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
^4iN/A -1 am not an Applicant that is a "contractor" as defined in MCC jsection 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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