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This record contains private information, which has been redacted from public viewing.
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Type:
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Ordinance
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Status:
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Passed
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Title:
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Zoning Reclassification Map No. 20-F at 320 W 83rd St - App No. 21138
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Topic:
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ZONING RECLASSIFICATIONS - Map No. 20-F
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Attachments:
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1. O2022-2743.pdf
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ORDINANCE flE /r 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 the Ml-1 Neighborhood Manufacturing / Business Park District symbols and indications as shown on Map No.20-F in the area bounded by A line 251 feet north of and parallel to West 83rd Street; a line 383.50 feet east of and parallel to South Stewart Avenue; West 83rd Street; and a line 203.16 feet east of and parallel to South Stewart Avenue, to those of a M2-1 Light Industry District. SECTION2. This ordinance shall be in force and effect from and after its passage and due publication. Common address of property: CITY OF CHICAGO APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE ADDRESS of the property Applicant is seeking to rezone: 320 W. 83rd Street Ward Number that property is located in: 21st Ward APPLICANT Hammad Ahmad ADDRESS 320 W- 83rd Street CITY ChiCa6° STATE IL ZIP CODE 60620 PHONE, EMAIL — ¦— - CONTACT PERSON XXX Is the applicant the owner ofthe property? YES NO If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed. Charles Levy OWNER Lincolnwood ADDRESS 7201 N- LinC°ln AveDUe CITY IL 60712 (312) 713-5922 STATE ZIP CODE bU/lz PHONE rezoning, please provide the following information: ATTORNEY Dean T. Maragos ADDRESS 1 N- LaSalle Street EMAIL-" CONTACT PERSON David Rosenfeld If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezonine. nlease nrovide the following information: Chicago IL 60602 CITY inicag° STATE ZIP CODE (312) 578-1012 dtm@maragoslaw.com PHONE FAX EMAIL
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.
N/A
On what date did the owner acquire legal title to the subject property? July 25» 2022
Has the present owner previously rezoned this property? If yes, when?
No
^ . . Ml-1 M2-1
9. Present Zoning District Proposed Zoning District
10. Lot size in square feet (or dimensions) 45,265.34 sq.ft,
Current Use ofthe property Existing 1 story vacant commercial building
Reason for rezoning the property To meet the Use Table and Standards section for the M2-1 to establish a cannabis business use
Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and
height of the proposed building. (BE SPECIFIC) The proposed use after the rezoning will be to establish a Cannabis business.- specifically a Cannabis Infuser Facility within the existing 1 story building at approximately 7,500 sq.ft. of 25,183
sq.ft. building. There are approximately jSU existing on-site parking spaces.
The existing 1 story building is to remain unchanged.
14. The Affordable Requrements Ordinance (ARO) requires on-site affordable housing units and/or
a financial contribution for residential housing projects with ten or more units that receive a zoning change which, among other triggers, increases the allowable floor area, or, for existing Planned Developments, increases the number of units (see attached fact sheet or visit www.cityofchicago.org/ARO for more information). Is this project subject to the ARO?
YES NO x
Page 2
V
COUNTY of eeeK^aw^r
STATE OF B^JQIS "7e<** '
//^MKAfr /IfjKflh . being first duly sworn on oath, states that all of die above
statements and the statements contained in the documents submitted herewith are true and correct
Signature of Applicant
Subscribed and Sworn to before me this dayof w XJf.
sotirv ;3 (HJ0SM672 m, Cc-mnik* Expire! -ci' 3CJ4
Date of Introduction:
FiJe Number:
Ward:
UNITED SURVEY SERVICE, LLC
CONSTRUCTION AND LAND SURVEYORS 7710 CENTRAL AVENUE. RTVER FOREST. tL «030S TEL (847) 209-1010 FAX ' (847) 200 - 3817 E-UAIL. USURVEYOUSANDCS COM
PLAT OF SURVEY
OF
THE EAST IB M FEET OF THE WEST 411 SO FEET OF TX SOUTH tt* 00 FEET OF THE WEST 1/1 OF THE SOUTH U ACMES OF THE WEST 11 OF THE NORTHEAST 1M OF SECTION U. T0WN3K? II NORTH. RANGE 11. EAST OF THE TKHD FftNCTAL HER DUN (EXCEPT FROM THE FOREGOING PREMISES THE SOUTH 1100 FEET THEREOF) M COOK COUNTY. UMX5
KNOWN as. m w. t;
KIMUCHI INDEX NUMBER.»- U - 22* ¦ 013 ¦ 0000
Wr83rd -STREET
STATE OF ILLMOIS )
)SS
COUNTY OF COOK )
I. ROY C LAWN1CZAK, DO HEREBY CERT FY THAT I HAVE SURVEYED THE ABOVE DESCRIBED PROPERTY AND THAI THE PLAT HEREON DRAWN IS A CORRECT REPRESENTATION OF SAID SURVEY
ORDERED BY CHICAGO TEAM
SCALE r = 15"
COMPARE THIS PLAT. LEGAL DESCRIPTION AND ALL SURVEY MONUMENTS BEFORE BULDMG. AND MMEMATELY REPORT ANY DISCREPANCIES TO THE SURVEYOR.
RIVER FOREST. ILLINOIS, AUGUST 21. A.D 2022.
WRITTEN NOTICE" FORM OF AFFIDAVIT (Section 17-13-0107)
August 30,2022
Honorable Thomas Tunney Chairman, Committee on Zoning 121 North LaSalle Street Room 304, City Hall Chicago, Illinois 60602
The undersigned, Dean T. Maragos, 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 of the 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 September 21,2022.
The undersigned certifies that the applicant has made a bona fide effort to determine the addresses ofthe 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.
Maragos & Maragos I, Chtd.
ATTORNEYS AND COUNSELORS AT LAW
1 North LaSalle Street • Suite 2242 Chicago, Illinois 60602 Phone: 312.578.1012 • Fa* 312.578.1016 E-Mail: dtm@maragoslaw.com
Hon. Samuel C. Maragos (1922-2005)
Hon. Dean T. Maragos*
*ALSO ADMITTED IN FLORIDA
OF COUNSEL
Francis X. Riley
(1912-2006)
August 30,2022
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 September 21, 2022, the undersigned will file an application for a change in zoning from a Ml-1 Limited Manufacturing/ Business Park District to a M2-1 Light Industry District on behalf of Hammad Ahmad, the applicant, for the property located at 320 W. 83rd Street.
The applicant intends to use the subject property to establish a Cannabis Infuser Facility within the existing 1 story building with onsite parking.
Hammad Ahmad is the applicant'and is located at 320 W. 83rd Street. The owner of the parcel is Charles Levy located at 7201 N. Lincoln Avenue, Lincolnwood, IL 60712. The contact person for this application is Dean T. Maragos, applicant & owner attorney, 1 North LaSalJe Street, Chicago, Illinois 60602, (312) 578-1012.
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.
Sincerely,
Dean T. Maragos DTM/pw|109|CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
SECTION I—GENERAL INFORMATION
A. Legal name ofthe Disclosing Parly snbmitting this EDS. Include d/b/a/ if applicable
Hammad Ahmad
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS isr
Q the Applicant
OR
| | a legal entity cinrently holding, or anticipated to hold within six months after (Sty action on
the contact, '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
namer., . ._- „ . .„ ... -.— ^-^-^
0R™~|
3. ? a legal entity with a direct or indirect right of control ofthe Applicant (see Section H(BX1)) State fee legal name ofthe entity in which, the Disclosing Party holds a right of control;
B. Bnsiness address of &eDisclosmgPBrQc ^320 w 83rd street
Chicago JL
CL Telephone:. _ .. ^^.^Fax: ^rr fo1^,
J3. Name^f contact person:- . .^T!!^!!!!!!.8^
E. Federal Employer IdmrfficntionNo. (^youhflye ohe):^
: and location of
__>king a zoning cnange iroir - — -Jtablish a
Cannabis Infuser Facility at 320 W. 83rd Street/
rth/ntrhlftflao Dept. of Planning & Bureau
If the Matter is a coiitract being handled by the C%fe Department ofPxocTjrement Services, please coTjaplete the following:- j
Scarification # ~ * arid Contract #.^-^
Page 1 of 15
SECTIONH-DISCLOSURE OR OWNERSHTP INTERESTS
Av
1. Indicate me ashn^
B
Person Q Iiinitedliab^
PrjbHchyreglsterBd'bHsin Q limited liability pa
n^Prjvarelv lield business cotd oration Q Joint venture
ale pi^etorshiri P] ^Kot-for-^ioflt corporation
TiGenB^r^rtiierahrp - G?menot-fbr-^^^
JaLjmitedfpBr^era^ QYes QNo
?Trust 0 Omer (please specify)
For legal entities, the state (or foreign comitry) of iiu^rporati or organization, if apalicable:
N/A
gg.*,; ...j...— f—I -r ¦"r,J'7/" ,1 - •• « •
For legal ratitiea rip t. or^ain^ed m ma State of Dlinois: Has the organization registered to do bnsifiessin meState o^IHinpte as a-foreign entity?
ONo ?OrgaiUzedmlffinois
B-. IF T^.DIS€a-OS]NG PARTY IS A LEGAL ENTITY: n/a
1. List helciw the f^names and tifle^ if applicable, of. (i) ell executive officersand afldmwters of
the entity; (ii) ft>r not-for-profit corporations. attmem!beis,4f airy, which ate legal entoies^if mere
aie ncisuch ineMiers, write "no members which are legal entities"); (iii) for brats, estates ot other
similar entirJeu, thetrustee, executor, arfamnstrator, oxsimilarly sihisted party; (iv) fbr general or
limited pailnewhrpa, Umftted liabOHy companies, limited liability parmevsntps or joint ventures,
eacb general p^er,ma^^ or legal entity thatdirectly or
hidirectrycontKj ofthe Applicant
NOTE: Each legal entity listed betownmst submit an EDS onhs own behalf
Name Thle
_ 4
2., Please provide the following information concerning each person oss legal entity having a direct or
iinlirecVcorfent ra^ within 6" months after City action) beneficial interest {including
ownership) fa Examples of Bncna^
coxpoxatibii, partnenih^'interest ma partnership or joint venture interest of araember prmanagsfinji
Pag£2ofI5
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state ^None."
NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.
Name Business Address Percentage Interest in the Applicant
SECTION TH- INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED OFFICIALS
Has the Disclosing Party provided any income or compensation to any City elected official daring me
12-month period preceding the date of this EDS? Q Yes QNo
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 tins EDS? £] Yes QNo
If "yes? to either of thej above, please identify below the name(8) of such City elected officials) and describe such income or compensation:
Does any City elected official or, to the best of the Disclosing Party** knowledge after reasonable
mqmry, any City elected official's spouse or domestic partner, have a financial interest (as defined in
Chapter 2-156 ofthe Municipal Code of Chicago ("MCC1)) in the Disclosing Party?
QYes ! jx]No
If "yes," please i&mtifyjbelow the name(s) of such City elected officials) and/or spouse(s)/domesiic parmeris) and describe the fmancial interest(s).
SECTION IV- DISCLOSURE OF SUBCONTI?ACTORS AND OTHER RETAINED PARTIES
The Disclosing Party-most disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any omerpersonor entity whom the Disclosmg^Party has retained or expects to retain in connection with the Matter, as well as the nature offhe^ielationsMp, and the total amount ofthe fees paid or estimated to be paid. The Dis closing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll. &me Disclosing Parry is micer^
Section, toe Disclosing P^arty must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 15
J
!
v Name (indicate-whetiier Business Relationshrp«to Disclosing Party Fees (Imijcate.Tðer
retained or anticipated Addtress (suocoafractor, attorney, odder esrirriated,') NOTE;
toberetamed)' lobbyist, etc;) iTiaurlynite,,cr0tbAais
Dean T. Maragos 1 N. LaSalle, Chicago, IL 60602 not BO acceptable r^OtlSe.
Retained „ torne^Jat Law ^ ^ pald ^>000 ' -
(Add sheets if necessary)
Q Check here if the Disclosing Party has not retained, nor expects to retain, any such pasons or entities. SECTION V - CERTD3ICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92«4 £5, substantial owners of business entities that contract with the City must remain in cornplianceiwith their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% ox more ofthe Disclosing Party been declared in arrearage on any child: support obligations by any Illinois court of competent jurisdiction?
QYes )7]Np JT"|No person directly or indirectly owns 10% or more ofthe Disclosing Party.
If "Yes," has the person-entered into a court-approved agreement for payment of aU support owed and is the person in compliance with that agreement?
QYes |}No
FATHER 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 mis EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection^wiih the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (be., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monUor the activity of specified agency vendors as well as help the vendors reform their business practices so they can bo considered, for agency contracts in the future, or continue with a contract in progress),
2. The Disclosing Parry 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, mcluding, butnot limited to, water and sewer charges, license fees, parking tickets^ property taxes 'and sales taxes, nor is the Disclosing Party delinquent m the rayment of any tax aduxinistered by the Illinois Department of Revenue.
Ver.2018-1 Page 4 of IS
£7 Tie Disclosing Party and, if the Dificlc^ng Party is alegal entity, all of those rjerBonsor endue* identified in Sericn$(B)(l) ot&h&S:
8. are iot presently debarred, suspended, proposed for debarment, declaredmehgible orvoluntarily exolnd^ fr^ any transactions by any federal, state or local unit of government;
b: havenpt} during lhe 5 years oeibre me date
aajudgedguilry, or had a cfvil judgirwntiemJeted a connection with: obtsiniig,
attempting/to obtain, or performing a public {federal state or local) transaction or contract under a jjnblictonsactionr a violation of federal orstate antitrust statates; liaud; embezzlement; tiian^fwger^ bribery; faisification>OT destruction of iec«rd^; making raise statements; or recdvmg sroleaprcjierry;
c. aremtpresently indicted for, or criin^ ofciviUy charged b^
stateor local) wimcommhlmgariyof meof&n^ above;
di have np^ during Hie 5 years before me date of tbjsBDS, had one or more public transactions (federal, stateor local) laminated for cause or default; and
e. have not, duringme 5 years before me date of this'EDS, been convicted, adnidgedgailty, orfound liable in a civil proceedings or in any cnrrmml or civil action, inchiding actions concealing enviranniental violat^ mstftntedby theGityorby^ federal govenuneat, any state, or any other unit oflocal govenmumfe
A. TJieDisoIosingPariy TmderstartdB and s^ coinply with the apph'cahte reqnirements ofMCC Chapters 2-5d (Inspector General) and 2-156 (Governmental Ethics).
5i Gerriflcatioiis^.^and^ cortpern;
•me'Displosmg Party;
any*ContractorD ^rneaningany coirb^toror.s^
connectlpn with thejMatter, including butnc^Iiii]^ to all persons or legal entities disclosed under Sectaon.]i\& disclosure or-Simcontractprs and Other Returned Parties0);
any °Af£lipedEnfity' (rneaning-a persoitor entftynEfiat* directly or indirectly: controls the Disctosmg^
cojnmbn: control of another person or entity). Indicia of control ihcludej wfihout KrnMon: interlocking management or ownership; identity^of ^interests among mrnUy members, shared facilities and eo^nW; cc^nmon use of employees; or organization of a business en% following ths meligibility of abusmesa entity to do buihiess with federal or state or local govenment, mcfuding the City, using substantiafly the same management, ownership, or prmchuds as the metigfole entity. Wrdi respect tDODDlractora, we term Af^
that directly err mdirectly controls the Contractor, is controlledBy % or, with me Contactor, is under common control of another person or entity;
any responsible official ofthe Discbsing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Snrity; acting pnrsrumt to the direction or aumozization of a responsible official of the Disdoring Party, any Contractor or any Affiliated-Eiificy (coUe^ctively•wAgenls,,).
VerJiOltf-i
Neither tie Disclosing Party, nor any Gc^tractar, nor any Affiliated Entity of either the Disclosing
Parry ox any Contractor, nor any Agenis have, aitringthe 5 years before the date of this EDS, or, with
respect to a Contmctor, an Affiliated Entity, or an Affiliated Entity of a Contractor (iuring the 5 years
before tbje date of ^ or Affiliated Entity's contract or engagement ihconnention with the
Matter*
a. bnTjed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a jmblic omiper or enjployee of the City, me State of Ermcris, or any agency ofthe federal gweomwnt
.or of any state orbcal goyenmient m
official capacity;
b, agreed or colluded with other bidders ot prospective bidders, or been a party to any snch agreement,
ot been convicted or iadjudged guilty of agreement or colrosion among bidders cr prospective bidders,
in restraint of fteedom of competrfionby agreem^ tobidafe or
ci made an. admission, of such conduct described in subparagraph (a) or f» aboveithat is amflffcr of record, but have not been prosecuted for such conduct; or
d. violated the provisions referenced in MCC Subsection 2-92-320Ca)(4)(Q>ritea^ Reouirm Wage); Neftberthe Disclosing Party, nor any Affiliated ETifity or Gmtractor, or any of their employees, officials, agents or partners, as barred from contraotrng^with any unit of state or local government as a result of engaging in.or being cc^cted of (1) bid-rigging m violation of720 'ILCS 5/33E-3; (JZ) Md-rotarmgin violarinn of720 ILCS 5/33B4; or (3) any similar offense of any state ot ofthe TJmtc3 States of America^ that grains me sameelementsasme offense of tel-rigging orKd-rotatmg.
Neither the Disclosing Party nor any AffihatedBntity is listed on a Sanctions List rnaintained by the limited States Department of Commerce, State* or Treasury, or any successor federal agency.
[FOR APPXIC$Nlj ONLYj (i) Neither the AppKcant nor any "controlling person" [seg MCC Chapter U2$, Arjficiel for appUc^3hy anddefined terms] of me Applicant is currently indictedor charged wrth^ or has adimtted guilt of, or has everbeen ocnivicted of; or placed mdersripervision for, any crmmtaloffense involving actual, attempted, or oonapiracy to commit bribery, theft, fraud, forgery, perjury; dishonesty or deceit against an'officer or employee ofthe City or any "sister agency";and (n) me Applicant understands and acknowledges ti^amtyhance with Article I isucormnuia^ reqmrement for doing; business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that A^c^VvipeHnanentcompliance timeframe supersedes 5^earcomphaacethnefra^
[FOR AP^LICAWT ONLY] The AppHcant and hs A£ffi»ted Entities will not use, Mr peprifcmejr surK^tractors to use, any facility listed as having amactive exclusion by the U;S. EPA on the federal System for Award Management ("SAM").
^R AfPUCANT.50NL"V] The Applicant will obtain from any (wntractrnVsuhcoatractora hired of to bo hired in corrnectioii with the MatiOT certifications equal in form and substance to those in Ceitfficatirjnfi (2) and (9) Bbovaandwi|LnbC
Ver^OlW | Bage$cfl5
vm cDn&acfor/si^^ notprovidesuch certifications or mat the Ajrf&^facwBtiiiD
believe b^ BOt provided or ram
II. If the Disclosing Party is unable to certify to any of m© above statements in tiisPartB (FnrSier Certificat$ons);mei^
If the letters "NA," the word "None," or no response appears on the lines above, it wilf be conclusively presumed that the Disclosing Party certified to the above statements.
12, To^e best of me'rjisoloamg Party's knowledge.after reEsonable mqniry, the foDbwingis a coinpl^.h^jofallcurrent employees of the DLscloaing Party who were, at any time dnrmg the 12-month periodpreceding the date of this BDS,anemployee,dr elected or appointedofEcial, of the City ofCbicago$f nonei r^&catewifc WA"ot^c^*).
.. m . . . ; _ _
a -
B.Tp msbest of me Dteclosmg Partes knowledge afto the following is a
c»injplece1ist of jail gifts -that the Disclosing P^riy ^;g|yen or caused to be given, al anytime during
the l^nmtfi^sriod ^recie^ or elected cr appointed
official, ofthe City of Chicago. Forpuxposes of this statement, a "gift" does not include; © arrytbing. nude.^erally available to City employees or to me general public, or (5) rood or drM|rrpyjded:m
"none"). Aa to anygrjffliated below, please also list the name ofthe Cityredpient
T~~w~~"~,"".—r^^w-j^fc-u-v-^^-i^- .-
r.i ^jtfj^^^fiw ,JtT-.Q*. St ^ . , .w-, ¦ ^^.*-.^>^f3L^ .
~-Maw-w«r-«Tn.~—.-»•%•»-. ....— - " ;.«.,,.»_^.r „ . —— ^
,~ ...
S3. J^TMCATJOnJoF STATDJS AS^ EINA^I^'INSTtJCMON
1. The TJiscloamgr^rty certifies that (check one)
Q*is fXJisnot
a ^^anci^ |mtitot|on^ as defined in MCC Section 2-32-455(b).
21 If the Disdcs^Party IS a financial institution, then the Disclosmg Party pledges:
are not and win nit a predatory Iender as de^ Weiurther
pledge that none of ourjaffaiates^ wiU become, a predatory lenderas defmedht
jifC^Cfa^nv&32 ^e undontand that be^ or becoming an afEBate of
ipjedtf^^ with me City."
PagB7ofl5
If^thej^sclc^injr Party, is unable to rnaketnispIe
-r*^**w*./.- ^ -
If the letters "NA," the word "None,* or no response appears an tiie lines above, it will .be c^icj^ive^presianed that the DMc^rngParry cerrified to the above statements.
D. CWTMCATJON REGAINING EuVANtM
Any words or terms affined in MCC Chapter 2-156 have the same meanings ft?used in this part TJ.
ti hiaxc^baacew^MCC SeelSoa2r4$64^Tp 4»i3aKkiBiiigftoty%knowledge
after reasonaBIe hmurry, does any official or employee of the City have a financial mterest in'his or her own name or in>me name of any other peracm or entity in the Matter?
Q*es
NOTE: Ifyou checked"Yes" to Item D(l)rjTOceed:to Items JJ® andD(3). If yon checked W to Item P(l), skip Items D(2) and 0(3) and proceed to Part E.
•2. Unless sold pursuant to a process of cpmpeiitive bidding, or otherwise rwrmrtted, e^) City elected
official m employee shall have a flnancialm^ or her own name or in the name of any
othecpersGa ero%3n the purchase of any pr^.exty that (i) belongs to tijeCity, or (if) iy sold for taxes or assessments, or (iii)is sold byvirtue^oflegid process at me suit of me City(coliectrveLy, "City Property Sale'1).! Cctnpensation for property taken rnirBttaat to the Government domain power dbes.npt constitute a financial interest vdtibjrlthe meanmg ofthis PartD.
Does the Matter involyB a Chy Property Sale?
QYes.- j ff|No.
3. If yon checked "Yes" to Item D(I), provide me names and business addresses of the City officials or oi^loyeerhavimj such^finariciai interest and identify the nature of the financial fcuerwt:
r
Nature of Financial Interest
r
* 1
4; The Disclosir^ Party further certifies that no prohibited financial interest in me Matter will be aarafred by any City official or employee.
Pags80flfi
:b
Hease check elthy (3) oi; (2) below. IfiheiTActoaLiig Party chec^
must disdr^e EPS all mfbnnaticm by (2). Failure to
comply with jthese:b^osure:re^ may make any contract entered info with tba QtyiSi connection with ^
The>Disclosmg Party verifies 4hatmeI)isclosmg Party has searched any and all records of
tr^Dl^bjsm&;P%^pnd any and all predecessor entj^ regarding records of ibvestrQentt or profits
fromskveiy^ slav^lder i^^ slavery era (incIudrnginsuranccpohcaK
issoedito stesfehalderk that provided coverage fbrdapage to or injury or death of their slays&X and meDisdosingPaityW
The DisclosingTJarty verifies that, as a result of condiMmg me search m Disclosing Party has found records of inveshnerits or profits tram slavery or slaveholdV insurnncfe policies. The Disclosing Party verities that me foUovvmgcotish^utes full tfsclosuroof allsuch recordsi jnclni^ the names of any and all slaves or slaveholders described in those records:
,.—i .j
5ECHON m-rr CERTmCATIONS FOR EEDERALLY FUNDED MATTERS
NOTE: i&rhe Matter is federally funded, co^Ietejthis Section VI If the Matter is not jrederalfrftu^^ to Section VII. Far purposes of this Section VI,,tax credits allocated by the Cityarrijpwceea^of debt obligations of the C% arenot;federaI fending.
A. CERTTHCATTON REGARDING LOBBYING
1. List below theiiarnes of all persons or entitles registered under uefederal Lobbying Disclosure Act of 1995, as amended, who have made tobbying contacts on behalf of the Disclosing Party with respect tp.-ffie Rfatten (Add sheets if necessary):
•-"
STBW3
(pffnp extdanation appears orbegms on the lines above, oraf me letters "NA" or if the word "None"
appear, £ wulbe jconciuBrvely. presumed^ means that NO persons cr entities
registe^ under the LobbyingDisclosure Act of 1995, as amended, have made tabbying contacts on
influence i
an^ person m; perrBrmorenti^to: yy'ej^
The£>isclrafaig Party has sot spent andor attempti tb irifliierice an officer or employee of any agency, as defined ; a member of Ckmgress? an officer or employee ofCcmgress, OTMempIbyee Page?rof^5
of a member of Congress, .in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement
The Disclosing Party wiH
which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies mat either: 0) his not an organization described insertion 501(c)(4) of the Internal Revenue Code of 1986; or (if) at is an orgamzstion described in section 501(c)(4) of the Internal Revenue Code of 1986but has sot engaged and will not engage in "Lobbying ActivMes,n as mat term is defined in the Lobbying Disclosure Act of1995, as amended.
~5i 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 subcontractors1 certifications for die dmation ofthe Matter and must makesuch certifications promptly available to the City upon request
B. CERTIFIGATION REGARDING EQUAL EMPLOYMENT OPPORTTJNTTY
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 writingat the outset of negotiations. .
N/A j
Is the Disclosing Parry the Applicant? ;
? Yes JNo I
If "Yes," answer the three questions below: <
I . Have yon developed and do youhave on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.) ^ Yes QNo
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Omtract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
QYes CD^0 ^Reports not required
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
?Yes QSfo
Vcr.2018-1 Page 10 of 15
If you checked *-No? tp question (ft *- f» above, please provide an explanation:
The Discing Party understands and agrees that:
The certificarioQS, 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
rrocuremant, Cityassistance, or other" Ciry action, end are material mdncements to-the City's execution
of any contract wm>ang«mer action with respect to the Matter. The DisolosmgPartyiiadersmn^
ftmuateom^ ordinances, aM regulations cinwMch this EDS is based
Tiie City's Goyernmental Ethics Ordinance,'MCC Chapter 2-156, imposes certain dories and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text erf this orrjinance enaa trainmg program is available on line at www.chVofcMca^.or^tMcg . and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St, Suite SGfyltScagb,"tL 60610, (312) 744^96.60; The Disclosing Party n^ comply tMyv^trds ordinance.
If mcQty detnnr^estliatarjy mform is false, incon^letecffinaccurato,
any contn^- or other^agreement in connection with; whicb. it is submitted maybe rescinded or be void
or voidable, and the City may pursue any remedies under the contract or agreement (if notresemded or
void), at law, or in equity, inclumn^terminatuig the Disclose 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 sMement ofrjiaterial factmay mcrbde incarceration and an award to me Ciry of treble
damages. i
It ia 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 mfbrmation provided in, and appended to, this EDS may be node publicly available on'&e-Inteniet, in responseito a Freedom of Morraation Act request, or otherwise. By completing and signing tins EDS, the Disclosing Patty waives andreleases any possible rights m? Claims which'it-may have against the'City in connection with the public release of mfbrmation cortfalned ta^ EDS; and also anthorizes the, Cityto veafy the accuracy of any mfbrmation
in tins EDS .
TJie iriforrr^cainrovidedm la me event of changes, the Discussing
Party inust simplement this EDS up to the time the City takes action on the Matter. If theMatteris a
contractfoing'haudied by the .City's Deparbasnt of ^curement Services, the.rjisclosingParty must
update this EDS SB the owtractiequires. NOTE: With respectto Matters subject to MCC Chapter
•1-23, Article I (irnposing PERMANENT INEHGIBT1J[TY for certain specified offenses), the
mibrmatica provided h regarding ehgarility must be kept current for a longer period, as wquhed
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 anuorized to execute this EDS, and all appfc'cable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained iathis EDS, and all applicable Appendices, are tme, accurate and complete as ofthe date furnished to theCity.
Hammad Ahmad
(Sign herli) j
:(P3rttl>r1ffi ofDisoIoamg'Partvl
Hammad Ahmad
(Print or type name of^erson aigrnng)
Manager 1
(Print or type Me ofperson signing)
i
Signed and sworn to before me on (date^V\\\jt
Page 12 of 15
CTTY OF CHICAGO ECONOMC DISCLOSURESTATEMENT AND ATMDAVIT
APPENDIXA
FAMILIAL REIATIONSHD7S WTTH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendtrls Wbe completed only by (a) the Applicant, and (fa) any legal entity which has a direct o wnership Interest In the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an Indirect crwnersbj^ interesttin the Applicant
Under MCC Secticm 2-154-'015, the Disclosing Party most disclose wfaemer such DMosing Party or any "AppHcahle Party" or any Spouse or Dom^cParbier thereof cummtlyhas a "faroilial rclationslnp" with any elected dty official or department head. A "femilial idationsrjip0 exists Jfiasof the.^ate tbisEDS is sighed, the DisclosmgParty or.any "Applicable Party' or any SpousBOTDcanestw Partner tnerepf is related to me nmycr, airy alderman, ^
department head as spouse or domestic partner or as any of me following, whether by blood or
adoption: parent, child, brother fer sister, aunt or uncle, niece or nephew, grandparent^ grandchild,
xamer^Di-h^ sonrin-Iaw, daughter-in-Uiw, stepfather or steprajofr^stepson or
stepdaughter, stepbrother or stejisister c*hali=b^
aAr^hcablft Partyf means (1) aB^ecmtive officers!:.dfthe Disclosing Party listed in Section
DJ3i.i.&,if.the of the Disclosing Party, if ttoDisclc^mg
Party is a general partnership; all general paxmarsr and%iited partners, of the DisclosthgParty, #tac Disclosing Patty is a limited partnership rnatwgers, managing members and membeisoftiie Disclosing Party, if the Disclosing Party i$ aHsc^t^'H^ili^^xo^xr^ (2) all t^cipai officers ofthe Disclosing Party; and (3) any personharmgntmrethan a 7.5% ownefship interest mmeDisciosing Party. T*rincipal officers" means the.pfesidenr, chief^operating officer, executive dhector, chief firiahoia! officer, treasurer or secretary of a-legVl eruity'or anyiwrson exercising similar a^cdty.
Does fiie Disclosing Party or any "Applicable Party or. any Spouse or Domestic Parraar thereof currently have a fffam^-reMorisnipa wffii an elected city official or department head?
If ye^ please identify below (1) the name and title of such person, (2) the name of thelegal entity to which snc^ r^rson is connected; (3) the name^^andJtltfe of'thB elected dty officifll or department heed to whomaui^ person has a familial relationship^ and (4) the. precise nature of such familial refctioiiship.
^«T-t»»t"--:— • ¦. —1
i ^-r — t- - ' •—-' - >-—> ¦ rr ¦
Page 13 of IS
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
QYes [x]No
If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
| | Yes QT No fJ^J The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
Page 14 of 15
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATJEMENT AND AFFIDAVIT
I APPENDIX C
PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION
1 "*
TJbis Appemiixi940De completed completing this EDS as a °coritractorn as
defined in MCC Section" 2-92-385. That section, which should he consulted ^wwamte^com^. generally covers a party to any agreement pursuant to which they: (i) •receive City of Chicago funds m 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 atrasiness on C% premises.
On behalf ofan Applicant that isn contractor pursuant to MCC Section2-92-385, Ihcrebyceitrfythat the Applicant is m compliance with MCC Section 2-92-385(b)(l) and (2), which prohibit (t) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary hiBtoryfxom caaeSt or former employers. I also certify that die Applicant has adopted afolicy that mcludesmoseprcm&itions.
'QYes
r^j N/A-I amnot anjApplicantthat is a 'Vxratraetor*' as defmed in MCC Section2-92-385. This certification shall serve as the afHdavit requiredby MCC Section 2-92-385(c)(l<). If you checked *W to the above, please explain.
m.
i i
Page 15 of IS
Charles Levy 7201 North Lincoln Avenue Lfncolnwood, Illinois 60712
The Honorable Tom Tunney Chairman City of Chicago Committee on Zoning City Hall
121 N. LaSalle Street Chicago, Illinois 60602
Re: Letter of Authorization for Zoning Amendment Applicant Agent- Hammad Ahmad - 320 W. 83rd Street
Dear Chairman Tunney,
I am the owner ofthe parcel located at 320 W. 83rd Street, Chicago, Illinois. I wanted to inform you that my authorized agent to file this application is Hammad Ahmad. If you've any questions please call our attorney Dean T. Maragos, (312) 578-1012.
Charles Levy Landowner
cc: Dean T. Maragos, Applicant Attorney (312) 578-1012
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:
Charles Levy
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
Q the Applicant
OR
[]a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR
J3] 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:
Property Owner
Business address of the Disclosing Party: 320 w. 83rd street
Chicago, IL
Telephone: _. ... Fax: Email:
Name of contact person: Dean T. Maragos, Attorney
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):1 ft Zoning Change: Ml-1 toM2- 1 inorder to construct a Cannabis
Infuser Facility.
City Council Zoning Committee
Which City agency or department is requesting this EDS? Bureau of zoning
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 Page 1 of 15
SECTION n - DISCLOSURE OF OWNERSHIP INTERESTS
A. NATURE OF THE DISCLOSING PARTY
£J Person
? Publicly registered business corporation Privately held business corporation
1. Indicate the nature of the Disclosing Party:
Sole proprietorship General partnership Limited partnership
U Limited liability company j| Limited liability partnership ? Joint venture
Not-for-profit corporation Is the not-for-profit corporation also a 501(c)(3))?
"1 Trust
? Yes rjNo | j Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
N/A
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?
fx^ Organized in Illinois
B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:
1. List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity; (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there are no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name Title
N/A
2. Please provide the following infonnation 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.
Name Business Address 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 Q 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 jjc| No
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:
N/A
Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosing Party? QYes |]No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).
N/A
SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES
The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll. If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.
Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "tb.d." is
not an acceptable response.
(Add sheets if necessary)
pxj 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?
? Yes [x]No QNo person directly or indirectly owns 10% or more of the Disclosing Party.
If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?
f~] Yes fj No
FURTHER CERTIFICATIONS
[This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.
Page 4 of15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) of this EDS:
are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;
have not, during the 5 years before the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and
have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section TV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").
Page 5 of15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;
agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or
made an admission of such conduct described in subparagraph (a) or (b) above that is a matter of record, but have not been prosecuted for such conduct; or
violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).
Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23, Article I for applicability and defined terms] 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").
[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
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.
11. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:
N/A
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
12. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").
13. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list 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)
QJ is jx] is not
a "financial institution" as defined in MCC Section 2-32-455(b).
If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."
Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):
N/A
If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS
Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
QYes
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?
QYes gxJNo
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
N/A
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 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 12. 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):
. pr75
(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 of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.
B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY
If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations. N^A
? 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.)
? Yes
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
? Yes QNo
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:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of this ordinance and a training program is available on line at www.citvofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, EL 60610, (312) 744-9660. The Disclosing Party must comply fully with this ordinance.
If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The infonnation 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 infonnation 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 r>erjury, 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.
Charles Levy
(Print or type exact legal name of Disclosing Party)
Chatles Levy
(Print or type name of person signing)
Owner
(Print or type title of person signing)
Signed and sworn to before me on (date)
Notary Public
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CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5%. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship'' with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any 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 ll.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?
QYes
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.
JUL
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CITY OF CfflCAGO ECONOMIC DISCLOSURE STATEMENT AND AFFD3AVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
QYes g]No
If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
QYes ? No ? The Applicant is not publicly traded on any exchange.
If yes to (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
N/A
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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)(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
No
? N/A -1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(1).
If you checked "no" to the above, please explain.
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