*2_( oo (p
ORDINANCE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the RS3 Residential Single Unit (Detached House) District symbols and indications as shown on Map No. 17-1 in the area bounded by
A line 268.21 feet North of and parallel to West Arthur Avenue; North Rockwell Street;
A line 235.21 feet north of and parallel to West Arthur Avenue; and the alley next west of and
parallel to North Rockwell Street.
to those of a RT3.5 Residential Two-Flat, Townhouse and Multi-Unit District.
SECTION 2. This ordinance shall be in force and effect from and after its passage and due publication
Common Address of Property: 6524 N Rockwell St., Chicago, IL, 60645
#2-1 oo(p
CITY OF CHICAGO
APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE
ADDRESS ofthe property Applicant is seeking to rezone:
Ward Number that property is located in: V\| CWo\ §0
APPLICANT %/t\\ jjcn^loj OYlA fhdCe^- &r\s\ )bncdrC^I
ADDRESS b6d\L^ M foc^L-U^il St- CITY CJmCO^O
STATE XL ZIP CODE b>Ot>CjS
PHONE
ONTACT PERSON %rti^ rksvllty ISt\>cq^ ybndloj
NO
Is the applicant the owner of the property? YES_
If the applicant is not the owner ofthe property, please provide the following information regaiding the owner and attach written authorization from the owner allowing the application to proceed.
EMAIL
If the Applicant/Owner ofthe property lias obtained a lawyer as their representative for the rezoning, please provide the following information:
Page 1
If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements.
7. On what date did the owner acquire legal title to the subject property? \ ^ ' \^C^rY\Jp&/-^lO iS
H. Has the present owner previously rezoned this property? If yes, when?
Present Zoning District|99|Proposed Zoning District^
Lot size in square feet (or dimensions') 35* t I j? l\' ^y" ' - 02-sj jJ- •
Current Use of the property f\eSl4(4tJldZ - 3p£>kty 2. sUr^ JbUiUy ¦
Reason for rezoning the property //? gllou> ^t, btslli QatA duflSllu 0^ t%e^
Describe the proposed use ofthe property after the rezoning. indicate the number of dwelling units; number of parking spaces; approximate square footage ofany commercial space; and height of the proposed building. (BE SPECIFIC)
9\eiQn\rx is jy cenvyj- f&strrrtMJt fa Cxr\ CulJUnorxJc JjyucMnj ond- jdW Wm m doses- ioflasnh or hr rttUvJ. m&mt ¦ ivildin* Cunt+Hi has
)i tint reov Ql ji,* wrlfi rvom M a, Mud- A/p CPmm^fu^t 0Sc,»* P^f^f °T^A-
14. The Affordable Requremenls Ordinance (ARO) requires on-site affordable housingVmits'and/or J a financial contribution for residential housing projects with ten or more units that receive a zoning change which, among othei" triggers, increases the allowable floor area, or, for existing Planned Developments, increases the number of units (sec attached fact sheet or visit www.cityofchicago.org/ARO for more infonnation). Is this project subject to the ARO?
YES NO
Page 2
COUNTY OF COOK STATE OF ILLINOIS
i-rrll (~UfjLv . &\ociM-f\r\(< 'fy/mMA , being first duly sworn on oath, states that all of the above statements arra the statements contained/in the documents submitted herewith are true and correct.
Subscrihgd-and Sworn to^bjsfbi'e me this
day of, CJ^x 20JV^ ^
Notary Public
For Office Use Only
Date of Introduction: File Number:
Ward:
Page 3
PLAT OF SURVEY
DESCRIBED AS
LOT 10 IN BLOCK 1 IN DEVON ROCKWELL ADDITION TO ROGERS PARK, A SUBDIVISION OF THE EAST 696.75 FEET OF THE SOUTHWEST QUARTER OF THE SOUTHEAST QUARTER OF SECTION 36, TOWNSHIP 41 NORTH, RANGE 13, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.
TOTAL LAND AREA: 4123.0 SQ. FT.
LEGEND
CHAIN LINK FENCE ¦ WOOD FENCE
IRON FENCE
CONCRETE PA VEMENT
ENCLOSED FRAME PORCH
- OPEN FRAME PORCH — -SIDE BOUNDARY LINE
- — - EASEMENT UNE
BLDG SETBACK LINE
—I— - CENTERLINE
#QV 35-3258 n-,0' ^ <* •' REGIS! fc*ED :J>
| LAND • 1 ': SURV£YOR : § % : STATE OF / j
% ILLINOIS / + f
ALL DIMENSIONS ARIZ SHOWN IN FEET AND DECIMAL PARTS THEREOF
STATE OF ILLINOIS COUNTY OF COOK
SIGNATURE DATE: ...NOVEMBER 11,2021
NO CORNERS WERE MONUMENTED PER CUSTOMER REQUEST.
SCALE: 1" = 16' ORDERED: TIRELL HENDLEY JOB NO : 21111111
FIELDWORK COMPLETION
date . NOVEMBER 10, 2021
MUNICIPALITY : CHICAGO
THE LEGAL DESCRIPTION NOTED ON THIS PLAT" IS A COPY OF THE ORDERS AND FOR ACCURACY MUST BE COMPARED WITH THE DEED.
I, ANDRZEJ MURZANSKI, AN ILLINOIS REGISTERED LAND SURVEYOR. DO HERBY CERTIFY THAT 1 HAVE SURVEYED THE ABOVE DESCRIBED PROPERTY AND THAT PLAT HEREON DRAWN IS A CORRECT REPRESENTATION OF SAID SURVEY.—
ANDRZEJ MURZANSKI PLS. NO. 35-3258 EXPIRES 11/30/2022
THIS PROFESSIONAL SERVICE CONFORMS TO THE CURRENT ILLINOIS
MINIMUM STANDARDS FOR A BOUNDARY SURVEY.
ANY DISCREPANCY IN MEASURMENT SHOULD BE PROMPTLY REPORTED TO THE SURVEYOR FOR EXPLANATION OR CORRF.CTION
FOR EASEMENTS, BUILDING LINES AND OTHER RESTRICTIONS NOT SHOWN ON THIS PLAT REFER TO YOUR ABSTRACT, DEED, TITLE POLICY AND LOCAL BUILDING REGULATIONS.
ANDRZEJ MURZANSKI
LAND SUR VEYORS, INC PROFESSIONAL DESIGN FIRM NO. IS4-004748
240 COUNTRY LANE GLENVIEW, IL 60025 PHONE : 847-486-8731
amurzanski@outlook.com
"WRITTEN NOTICE" FORM OF AFFIDAVIT (Section 17-13-0107)
April 27, 2022
Honorable Thomas M. Tunney Chairman, Committee on Zoning 121 North LaSalle Street Room 304, City Hall Chicago, Illinois 60602
The undersigned, Tirell Hendley and Stacey-Ann Hendlev. being first duly sworn on oath deposes and states the following:
The undersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Chicago Zoning Ordinance, by sending written notice to such property owners who appear to be the owners ofthe property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said "written notice" was sent by First Class U.S. Mail, no more than 30 days before filing the application.
The undersigned certifies that the notice contained the address of the property sought to be rezoned; a statement of the intended use of the property; the name and address of the applicant; the name and address of the owner; and a statement that the applicant intends to file the application for a change in zoning on approximately 27-APRIL-2022.
The undersigned certifies that the applicant has made a bona fide effort to determine the addresses of the parties to be notified under Section 17-13-0107 ofthe Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be served.
Subscribed and Sworn to before me this
Notary Public
i'5 day of -Apf1[ ,20
SAMPLE FORM OF LETTER TO SURROUNDING PROPERTY OWNERS
April 1,2022
Dear Property Owner:
In accordance with the requirements for an Amendment to the Chicago Zoning Ordinance, specifically Section 17-13-0107, please be informed that on or about April 27, 2022, the undersigned will file an application for a change in zoning from RS-3 to RT-3.5 on behalf of the applicant for the property located at 6524 N Rockwell, Chicago, IL.
The applicant intends to use the subject property for The Current building is a 2 story brick building total of 3,631 sq.ft. There are currently 2 dwelling units 3 bedrooms/1.5 baths each. The intent convert the basement and add an additional unit and utilize this new space to accommodate 2 bedrooms and 1 bath for a total of 3 dwelling units.
The applicant and owner are located at 6524 N Rockwell, Apt. 2, Chicago, IL, 60645. The contact person
for this application is Tirell Hendley(Owner) ' d Stacey-Ann Hendley(Owner)
Please note that the applicant is not seeking to rezone or purchase your property. The applicant is required by law to send this notice because you own property within 250 feet of the property to be rezoned.
Very truly yours,
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I - GENERAL INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Check ONE ofthe following three boxes:
Indicate whpttfcr the Disclosing Party submitting this EDS is:
the Applicant OR
Q a legal entity currently holding, or anticipated to hold within six months after Cily 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
Q a legal entity with a direct or indirect right of control ofthe Applicant (see Section 11(B)(1)) State the legal name ofthe entity in which the Disclosing Party holds a right of control:
13. Business address ofthe Disclosing Party:
Telephone: Fax: Email:
Name of contact person: ~~
E. Federal Employer Identification No. (if you have one):
Brief description ofthe Matter to which this EDS pertains. (Include project number and location of property, if applicable):
tiacntnj ZJfioJr bisiUrVj r\S3h dT3S h oJd ftasertcd <^r tfjf ^IpciueMSh
Which City agency or department is requesting this EDS? div/CMI ^ 2W/fr/y Pla/iWrtj asul hzx/do^tflW-l'
If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification # _ i\rfr and Contract # A/ft
Ver.2018-1 Page lof 15
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS A. NATURE OF TFIE DISCLOSING PARTY
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
[~~| Limited liability company
I | Limited liability partnership
| | Joint venture
| | Not-for-profit corporation
(Is the not-for-profit coiporation also a 501(c)(3))?
? Yes DNo [ | Other (please specify)
For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
lyA
For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?
| [ Yes Q No Q Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management of the Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
A/ft - no If cud ssUih&
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
i
j
I limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
j state "None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
iring tin
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
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 [tj^fo
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 ofthe Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 ofthe Municipal Cods of Chicago ("MCC")) in the Disclosing Party? [] Yes
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects 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 Cily whether disclosure is required or make the disclosure.
Page 3 of 15
retained or anticipated to be retained )
Address (subcontractor, attorney, lobbyist, etc.)
paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.
(Add sheets if necessary)
Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
Yes \^^o QJ 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? ^jfir
QYes ?No NrB. 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 ofany public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment ofany 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 ofany tax administered by the Illinois Department of Revenue.
Page 4 of 15
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
NlIf the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all current employees of the Disclosing Party who were, at any time during the 12-
month period preceding the date of this EDS, an employee, or elected or appointed official, of the City
of Chicago (if none, indicate with "N/A" or "none").
N/\ ¦ =
13. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N A
C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
Qis [JjXnot
a "financial institution" as defined in MCC Section 2-32-455(b).
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."
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):
NA =z
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
1. In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
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 Q No
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.
1 \yT. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.
U2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:
SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS
NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1, List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):
(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.)
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 ofany 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 ofany federally funded contract, making any fedcr-iiiiy -funded grantor-loan, entering rnto any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.
? No
Is the Disclosing Party the Applicant?
? Yes
If "Yes," answer the three questions below:
? No
1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
QYes
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
? Yes ? No
If you checked "No" to question (1) or (2) above, please provide an explanation:
Page 10 of 15
SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION
The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution ofany contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.cityofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is siibmitted may be rescinded or be' void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement" of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.
Page 11 of 15
CERTIFICATION
Under penalty ot"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.
(Sign here)
(Print c/r type exact lega/name of Disclosing Pa/ty) By:
(Print or type name of person signing) '
(Print or type title of person signing)
Signed and sworn to before me on (date) 03? \ 10 j at pwll-o ^ County, C\xt^^^- (state).
Notary Public Commission expires:
Page 12 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed 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 ofthe Disclosing Party listed in Section II.B. 1 .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers 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"jarith 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 ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.
Page 13 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
1. Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
QYes
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?
o ? 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.
On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.
i/A -1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385.
[J Yes ? No
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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