Office of the City Clerk - Record #: O2022-3579

• Record #: O2022-3579
• Type: Ordinance
• Status: Passed
• Intro date: 10/26/2022
• Current Controlling Legislative Body: Committee on Housing and Real Estate
• Final action: 11/16/2022
• Title: Amendment of redevelopment agreement with Joudeh Investments LLC and MKB Business Strategies LLC for lot replacement under Working Families Ordinance
• Sponsors: Lightfoot, Lori E.
• Topic: AGREEMENTS - Redevelopment, - PROPERTY - Sale

Date	Journal Page Number	Action By	Action	Result
11/16/2022	56721	City Council	Passed	Pass
11/15/2022		Committee on Housing and Real Estate	Recommended to Pass
10/26/2022	52737	City Council	Referred

OFFICE OF THE MAYOR
CITY OF CHICAGO
LORI E. LIGHTFOOT MAYOR
October 26. 2022










TO THE HONORABLE, THE CITY COUNCIL OF THE CITY OF CHICAGO


Ladies and Gentlemen:

At the request ofthe Commissioner of Housing, I transmit herewith an ordinance authorizing an amendment to a City Lois for Working Families ordinance to replace a lot.

Your favorable consideration ofthis ordinance will be appreciated.


Very truly yours.

Mayor
ORDINANCE

WHEREAS, the City of Chicago (the "City") is a home rule unit of government pursuant to Article VII, Section 6(a) of the 1970 State of Illinois Constitution and may exercise any power related to its local governmental affairs; and

WHEREAS, the City Council of the City (the "City Council"), by ordinance first adopted on November 8, 2017 ("Program Ordinance") and published in the Journal of Proceedings of the City Council (the "Journal") for such date at pages 59287 through 59295, established the City Lots for Working Families Program ("City Lots Program"), to assist with the construction of high-quality, owner-occupied single-family housing affordable to working families; and

WHEREAS, the Program Ordinance authorizes the Department of Housing ("DOH") to (a) sell City Lots (as defined in the Program Ordinance) with an appraised value of $175,000 or less for $1 per City Lot to approved developers of projects that meet certain development parameters; (b) exempt such projects from MBE/WBE Requirements and City Residency Hiring Requirements if all City Lots within such project have an appraised value of $125,000 or less, and (c) waive certain City fees for such projects; and

WHEREAS, the City Lots Program further authorizes DOH to permit the sale of up to twenty-five percent (25%) of the homes in a project at market rates, and to adapt program requirements, including modifying or eliminating the homebuyer mortgage set forth in the Program Ordinance; and

WHEREAS, pursuant to ordinances adopted on (i) February 16, 2000, as amended on March 12, 2008, September 8, 2011 and February 10, 2016, with respect to the Central/West Redevelopment Project Area, (ii) February 27, 2002, as amended on June 8, 201L, with respect to the Chicago/Central Park Tax Redevelopment Project Area, and (iii) May 17, 2000, as amended on April 14, 2010, May 9, 2012 and December 9, 2015, with respect to the Midwest Redevelopment Project Area (each, a "Redevelopment Area" and collectively, the "Redevelopment Areas"), the City Council: (i) approved redevelopment plans and projects (each, a "Redevelopment Plan" and collectively, the "Redevelopment Plans"), pursuant to the Illinois Tax Increment Allocation Redevelopment Act, as amended (65 ILCS 5/11-74.4-1 et seq.) (the "TIF Act"); (ii) designated the Redevelopment Areas as redevelopment project areas pursuant to the TIF Act; and (iii) adopted tax increment financing pursuant to the TIF Act as a means of financing certain Redevelopment Area project costs incurred pursuant to the Redevelopment Plans; and

WHEREAS, pursuant to ordinance ("Project Ordinance") adopted on September 14, 2021, and published in the Journal for such date at pages 35543 through 35599, the City, acting through DOH, has previously entered into an Agreement for the Sale and Redevelopment of Land, dated on or as of March 15, 2022, with a joint venture comprised of Joudeh Investments LLC and MKB Business Strategies LLC, each an Illinois limited liability company and together with any single purpose entity owned and controlled by them, the "Developer", for the sale of the City-owned parcels commonly known as 210 and 212 South Hoyne, 2256 and 2339 West Monroe, 2654 West

Adams, and 3262 and 3264 West Walnut, Chicago, Illinois (each a "City Lot," and, collectively, the "City Lots"), which are located in the Redevelopment Areas and legally described on Exhibit A attached hereto (the "Property"); and

WHEREAS, pursuant to the Redevelopment Agreement, the Developer shall purchase the Property from the City for Eight Dollars ($8.00) and build eight (8) affordable single family homes on the Property (the "Project"); and

WHEREAS, the Project is consistent with the goals and objectives ofthe Redevelopment Plans; and

WHEREAS, DOH has recommended, and the Developer has agreed, to delete from the Redevelopment Agreement the City Lot located at 2339 West Monroe (the "2339 West Monroe Parcel") and to substitute for it the parcel commonly known as 2433 West Congress Parkway, which is legally described on Exhibit B attached hereto (the "Congress Parcel") and located in the Western/Ogden Redevelopment Area. Tlie City and the Developer desire to amend the definition of "Property" in the Redevelopment Agreement to include the Congress Parcel and to delete the 2339 West Monroe Parcel. The Congress Parcel is a City Lot; and

WHEREAS, the appraised fair market value of the Congress Parcel as of October 20,2021, is $60,060; and

WHEREAS, pursuant to Resolution No. 22-CDC-21 adopted on June 14, 2022, by the Community Development Commission ("CDC"), the CDC authorized DOH tq advertise its intention to enter into a sale with the Developer for the redevelopment of the Congress Parcel, approved DOH's request to advertise for alternative proposals, and approved the sale of the Congress Parcel to the Developer if no alternative proposals were received; and

WHEREAS, pursuant to Resolution No. 22-024-21 adopted on June 16, 2022, by the Plan Commission of the City (the "Commission"), the Commission recommended the sale ofthe Congress Parcel; and

WHEREAS, public notices advertising DOH's intent to convey the Congress Parcel to the Developer and requesting alternative proposals appeared in the Chicago Tribune on June 17 and 24, and July 1, 2022; and

WHEREAS, no alternative proposals were received by the deadline indicated in the aforesaid notices; now, therefore,

BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:

SECTION 1. The recitals set forth above are incorporated herein by reference and made a part hereof.

SECTION 2. The Developer is hereby designated as the developer for the Project, as amended by this ordinance to substitute the Congress Parcel for the 2339 West Monroe Parcel,

pursuant to the TIF Act.

SECTION 3. The sale of the Congress Parcel for $1.00 is hereby approved. This approval is expressly conditioned upon the City entering into an amendment to the Redevelopment Agreement with the Developer, in which the Congress Parcel is substituted for the 2339 West Monroe Parcel. The commissioner of DOH ("Commissioner"), or a designee of the Commissioner, is each hereby authorized, with the approval of the City's Corporation Counsel, to negotiate, execute and deliver an amendment to the Redevelopment Agreement and such other documents as may be necessary or appropriate to carry out and comply with the provisions of this ordinance. Such documents may contain terms and provisions that the Commissioner, or a designee of the Commissioner, deems appropriate, including indemnification, releases, affidavits and other documents as may be necessary to remove exceptions from title with respect to the Congress Parcel or otherwise reasonably necessary or appropriate to consummate the transactions contemplated hereby.

SECTION 4. Die Mayor or her proxy is each hereby authorized to execute, and the City Clerk or the Deputy City Clerk is each hereby authorized to attest, a quitclaim deed or deeds conveying the Property to the Developer, or to a land trust of which the Developer is the sole beneficiary, or to a business entity of which the Developer is the sole controlling party or is comprised of the same principal parties, subject to those covenants, conditions and restrictions set forth in the Redevelopment Agreement, as amended.

SECTION 5. Tlie waiver of those certain fees described on Exhibit C to the Redevelopment Agreement that was attached to the Project Ordinance remain in effect and also shall apply to the Congress Parcel. The City shall deem the Project, as amended by this ordinance, to qualify as "Affordable Housing" for purposes of Section 16-18 of the Municipal Code of theCity ("Municipal Code"). Given the applicable restrictions with respect to the maximum purchase price and maximum income for the residents of the Project, Section 2-44-080 of the Municipal Code shall not apply to the Project.

SECTION 6. If any provision of this ordinance shall be held to be invalid or unenforceable for any reason, the invalidity or unenforceability of such provision shall not affect any of the other provisions of this ordinance.

SECTION 7. This ordinance shall take effect upon its passage and publication.
EXHIBIT A LEGAL DESCRIPTION OF PROPERTY
(Subject to Final Survey and Title Commitment)
Property Commonly Known as 210-212 South Hoyne, Chicago, Illinois
LOT 6 AND THAT PART OF LOT 5 COVERED BY BUILDING ERECTED ON SAID LOT 6 DESCRIBED AS FOLLOWS:
COMMENCING ON THE SOUTH LINE OF LOT 5 AT THE POINT 17 FEET 7 1/4 INCHES MORE OR LESS WEST OF THE EAST LINE OF SAID LOT 5, RUNNING THENCE NORTH TO THE CENTER OF THE PARTY WALL 2 FEET MORE OR LESS THENCE WEST TO THE WEST END OF THE BUILDING ON SAID LOT 6, 56 FEET 1-1/4 INCHES MORE OR LESS, THENCE SOUTH 2 FEET MORE OR LESS AND THENCE EAST ALONG THE SOUTH LINE OF SAID LOT5 TO THE PLACE OF BEGINNING, ALL IN BLOCK4 IN THE SUBDIVISION OF THE EAST 501.62 FEET OF THE NORTH 1622 FEET OF THE WEST 1/2 OF THE EAST '/2 OF THE NORTHWEST 1/4 OF SECTION 18, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

PIN: 17-18-117-031-0000




Property Commonly Known as 2256 West Monroe, Chicago, Illinois

LOT 11 AND THE WEST 16 FEETOF LOT 12 OF HOARD AND POTWIN'S SUBDIVISION OF ALL THAT PART LYING NORTH OF MONROE STREET OF LOT 6 AND THE EAST 112 OF LOT 5 IN BLOCK 9 IN SECTION 13, TOWNSHIP 39 NORTH, RANGE 13, AND THE WEST 1/2 OF THE NORTHWEST 1/4 OF SECTION 18, TOWNSHIP 39 NORTH, RANGE 14, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN ROCKWELL'S ADDITION TO CHICAGO, IN COOK COUNTY, ILLINOIS.

PIN: 17-18-101-026-0000



Property Commonly Known as 2339 West Monroe, Chicago, Illinois

THE EAST 24 FEET OF THAT PART SOUTH OF MONROE STREET, OF LOT 1 IN BOCK 9 IN ROCKWELL'S ADDITION TO CHICAGO, BEING A SUBDIVISION OF THE

NORTHEAST 1/4 OF SECTION 13, TOWNSHIP 39 NORTH, RANGE 13, AND THE WEST 1/2 OF THE NORTHWEST 1/4 OF SECTION 18, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

PIN: 17-18-105-006-0000




Property Commonly Known as 2654 West Adams, Chicago, Illinois

LOT 40 IN GEORGE W. RUSTS SUBDIVISION OF LOTS 12, 13, 16, 17 AND 20 (EXCEPT THE EAST 67 FEET OF SAID LOT 20) IN BLOCK 2 IN ROCKWELL'S ADDITION TO CHICAGO IN THE NORTHEAST 1/4 OF SECTION 13, TOWNSHIP 39 NORTH, RANGE 13, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

PIN: 16-13-209-021-0000




Property Commonly Known as 3262 West Walnut, Chicago, Illinois

LOT37 IN BLOCK 8 IN THE SUBDIVISION OF BLOCKS 2, 5, 8 AND 11 IN TYRRELL BARRETT AND KERFOOTS SUBDIVISION OF THE EAST 1/2 OF THE SOUTHEAST 1/4 OF SECTION 11, TOWNSHIP 39 NORTH, RANGE 13, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

PIN: 16-11-408-067-0000




Property Commonly Known as 3264 West Walnut, Chicago, Illinois
LOT 36 IN BLOCK 8 IN THE SUBDIVISION OF BLOCKS 2, 5, 8 AND 11 IN TYRRELL BARRETT AND KERFOOTS SUBDIVISION OF THE EAST 1/2 OF THE SOUTHEAST 1/4 OF SECTION 11, TOWNSHIP 39 NORTH, RANGE 13, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.
PIN: 16-11408-066-0000

EXHIBIT B

LEGAL DESCRIPTION OF CONGRESS PARCEL

(Subject to Final Survey and Title Commitment)


Property Commonly Known as 2433 West Congress Parkway, Chicago, Illinois


THE WEST 26 FEET OF THE EAST 53 FEET OF LOT 18 IN ROCKWELL'S ADDITION TO CHICAGO, BEING A SUBDIVISION OF THE NORTHEAST % OF SECTION 13, TOWNSHIP 39 NORTH, RANGE 13 AND THE WEST Vi OF THE NORTHWEST % OF SECTION 18, TOWNSHIP 39 NORTH, RANGE 14, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.
PIN: 16-13-234-017-0000
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:



Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:
p^. 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
[ ] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:

Business address ofthe Disclosing Party:
- - — (Lh \ aas? o , XL. ic OteO 1

Telephone: ^oS~~ Fax: ZiSt-T5'b-^3>%7 Email
Name of contact person: tUg,N,n \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): (Li-ki k*f> f^A. l,Oo,»j1\0 S. Ho/»it- (LWjo.Xi J £iU. 3, HoyVfc. C.liicsiOf.JjL' <& k) Adam* dhtr,(,>.,Jl
Which City agency or department is requesting this EDS? ^ip/^hiWidr 0- /"/a^nvij
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #
Vcr.2018-1 Pagclof'15

SECTION II -
- DISCLOSURE Ol OWNERSHIP INTEREST'S

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party.
| | Person j | Limited liability company
' | Publicly registered business corporation f ] Limited liability parmership
! ] Privately held business corporation [,/] Joint venture
[ j Sole proprietorship [ | Not-for-profit corporation
! | General partnership (Is the not-for-profit corporation also a 501(c)(3))':
! ] Limited partnership [ } Yes [ J No
! | Trust | ] Other (please specify)


2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
X 11;^.. ) S

3. .For legal entities not organized in ihe State of Illinois: Has the organization registered lo do
business in the State of Illinois as a foreign entity'.'

| | Yes [ ] No ^Organized in Illinois

H. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

i List below the full names and titles, if applicable, of: (i) all executive officers and all directors of ihe. entity; ui) 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 lhe day-to-day management of the Applicant.

NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title
!'-J'; iv . "•. t* ,i\ i ',•<• ; . , 'M ("i 'O <; i -v. - j r\.'.' '.V-l/^-ft.
—.— —r~~rA 7~ ¦¦ ' ~ :



2. Please provide the following information concerning each person or legal entity having a direct or indirect, current ot prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest ofa member or manager in a

Puiie 2 of 15

limited liability company, or interest of a beneficiary ofa trust, estate or other similar entity. If none, state "None."
NOTE: Each legal eniity listed below may be required to submit an Rl)S on its own behalf.
Name Business Address Percentage Interest in the Applicant
i >
¦¦xii4a Uui^rbuv:-.^ LJ^>- Af pott. Pfc? T^m-^Vi^/c-. - & ":V _,



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 die
12-monih period preceding the date ofthis EDS'.' ! ] Yes iy] No

Does the Disclosing Party reasonably expect io provide any income or compensation to any City
elected official during the 12-month period following the date ofthis LIDS'' [ ] Yes [kJ No

If 'yes" to either of the above, please identify below the name(s) of such City elected olTicial(s) am! describe such income or compensation:



Does any Cily elected official or. to the best ofthe Disclosing Party's knowledge after reasonable
inquiry, any Cily elected official's spouse or domestic partner, have a financial interest (as defined in
Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party'.'
[ J Yes i)<] No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/doincstic panner(s) and describe the financial interests).



SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PAR I IKS

The-Disclosing Party-must disotose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-1 56). 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. Ifthe Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Pagu 3 of 15

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
'^f2 ^ r^lo.trt fnc/J not an acceptable response. .


T~S t Cot\f-rc-C.-rc;rS (rye - Ryjffii^J ~ ^^y^fti^Xt- "GfrAO-f &iv.Kc.ft*- " Zz^rrxhcifa...
(Add sheets if necessaoO'^ba'-WV SUieH tiJded (MtS sw.^« -W^/ )

[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.

Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes [Vj No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

I ] Yes [ ] No
FURTHER CERTIFICATIONS

[This paragraph 1 applies only ifthe Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, lax or other source oflndebtedness 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 Parly delinquent in the payment of any tax administered by the Illinois Department of Revenue.


Page 4 of 15
SWORN STATEMENT FOR CONTRACTOR AND SUBCONTRACTOR TO OWNER AND TO CHICAGO TITLE AND TRUST
Commitment No.:
State of Illinois County of Cook
THE AFFIANT, being first duly swom, on oath deposes and says that he/she is of TBI Contractors Inc, 8905 Moore Dr, Bridgeview, IL, 60455 that has contract with MKB Business Strategies LLC And Joudeh Investment LLC & , owner for the following described premises in Cook County, to wit: 3262 W Walnut St, Chicago, IL. 60614/
That, for the purposes of said contract, the following persons have been contracted with, and have furnished, or arc furnishing and preparing materials for, and have done or are doing labor on said improvement. That there is due them, respectively, the amounts set opposite their names for materials or labor as stated. That this statement is a full, true and complete statement of all such persons, the amounts paid and the amounts due or to become due to each.
N inie and Address
Maris V Contracting. Inc. 2818 N . 73rdCl. Elmwood. IL 60707
Kind of Work
Excavating
tEilru
-Credit!
Adjuited Contract Total
Attention Net of Previous N ef Amount
Hulanee lo
Ami ofConlr.cl "cZ'^'l) """r\',™"rt, T^V.'yZn, ,. H"°,n":„",,f
* ' ' ' (Inc. Retention)
SU.50O.O0 10.00 SO.OO
513.500.00 SO.OO SO.OO SO.OO 513,500.00
Maria V Contracting. Inc. 2818 N .7>dO. Elmwood. IL 60707

OOM Con iruccion Inc 2720 W Chicago Ave. Chicago, il 60622
foundation
?Ealraj
¦Credils
Adjusted Contract Total
Carpentry +Extras -Credits
Adjusted Contract Tntal
130,000.00 SO.OO
so.oo
530,000.00
J40.JOO.00 SO.OO SO.QO
40,500.00
United Builders Croup CO 2700 Patriot Blvd Glenview, IL. 60026
Masonry
+Ealru
•Credita
Adjusted Contract Total
113,0011.00 SO.OO SO.OO
SI 3.000.00
Pawcl's Plumbing 3228 NPIainfield Ave Chicago, IL60.6M
sewer/ water +EJ1TM Credits
Adjuited Contract Total
SI 5,000.0(1 SO.OO SO.OO
SI 5,000.00
Pawcl's Plumbing 3228N PlamfieldAve Chicago, IL 60634
Plumbing
-•-Extras
•Credils
Adjusted Contract Tolal
520,000.00 SO.OO SO.OO
530,000.00
Mechanical Brothers 22W4l8HillcrcailTcrr. Medioah.IL 60137
HVAC ? Extras -Credita f
Adjusted Contract Total
S9.200.00 SO.OO
so.oo
59,100.00
Bolek Electric
673 Brentwood Ave
Elk Grove Village, IL 60007
Electrical
?Extras
-Credils
Adjusted Contract Total
SI5.O0O.0O SO.OO SO.OO
515,000.00





Escrow No: Draw No : 1 Pa98 : 1
Name end Addren Climate Guard
Kind cfWnrk
windows, + Fxlras -Credits
Adjusted Contract Total
Arm of Contract
56,500,00 50,00 SO.CO
56,500.00
Retention (Inc. Current)

Hecomeour (Inc, Retention)
Net or Previous Net Amount Payments This Pevmenl

JO.OO 50.00 56,500.00
Lucas Construction 1208 N Doe Rd Palatine, IL. 60061

SafeT
3740 2Slh Ave Shlllcr Park, IL 60176

C.R.D.C. Conslruclion, LLC 2105 W Walton Slrccl, Chicago, IL 60622

C.R.D.C. Construction, LLC 2105 W Walton Slrccl, Chicago, IL 60622

C.R.D.C Conslruclion, LLC 2105 W Walton Street, Chicago, IL 60622
Roof, siding, from panels ?Extras
-Credils
Adjuited Contract Total
low voltage ? Extras -Credits
Adjusted Conlract Total
Drywill ?Extras -Credils
Adjusted ContractTotal
Insulation
?Extras
-Credits
Adjusted Contract Tslal
painting ? Extras -Credits
Adjusted ContraclTnfal
S23.lt 00.00 SO.OO 50,00
513,800.00
52,800.00 SO 00 SO.OO
S2.H00.00
S7.SC0.00 SO.OO SO.CO
57,500.00
53.000.00 SO.OO SO.OO
53.000.00
S4.0OO.C0 SO.CO SO.OO
54.000.00
DOM Properties Investment Inc 2720 v7 Chicago Ave Chicago. IL60622
fence ? Extras -Credits
Adjusted Conlract Total
56,500.00 SO.OO SO.OO
56,500.00
C.S.O.C. Construction, LLC 2I0S \v Walton Slrccl, Chicago, IL 60622

C R.D.C. Construction, LLC 2105 IV Walton Street, Chicago, IL 60622

JD whiripool&bath outlet inc 2730 ."forth Elston Ave Chicago, IL 6064 7
Floor Covering
Extra* -Credils
Adjusted Contract Total
millwork&hardware
Extras -Credils
Adjusted Contract Total
plumbing fixtures ? Extras -Credils
Adjusted Conlract Total
55,000.00 SO.OO 50.0G
SS.000.00
S6.ooa.oo so oo so.oo
56,000.00
53,500.00 SO 00 SO.OO
53,500.00
DOM Properties Investment inc 2720 W Chicago Ave Chicago.IL 60622
Interior nalrs
?Extras
-Credits
Adjusted Cuntrict Tutsi
52,500.00 SO.OO
sn.ao
51,500.00
DOM Properties Investment Inc 2120 W Chicago Ave Chicago, IL 60622
Exterior stairs
?Extras
-C-cdiH
Ad|usled ContractTotal
S 4,000.00
so.oo so.oo
S4.0OO.0O
I30M Properties Investment Inc 2730 W Chicago Ave Chicago, IL 60623
countcrtops ? Extras -Crcd.ls
Adjusted Contract Tntal
si.ooa.oa
SO 00
so.oo
52,000.00
COM Properties Investment Inc 2720 W Chicago Ave Cnicago. IL 60622
Appliances
?-Extras
-Credils
Adjusted Conlract Totsl
53,000.00 SO.OO 50.00
53,000.00
Kmiini LLC 2720 W Chicago Chicago.IL 60622
cabinets ?Extras -Credits
Adjusted Contract Total
S3,000.00 SO.OO 50.00
53,000.00
DOM Properties tnvainienl Inc 2720 W Chicago Ave Chicago, !L 60622
tiles ?Extra,
¦Credils
Adjuited Contract Total
55,000 00 SO 00 SO.OO
55,000.00

Escrow No : Orow No : 1 Pa3° ::
Name and Addrcis
OP Company glass
118] Baity dr
Lake Zurrlch, IL 60047
Kind ofVVorU
shower, mirrors ? Extras -Credita
Adjusted Contract Total
Amt of Contract
S700.00 JO.OO JO.OO
$700.00
Retention (Inc. Current)

10.00
Net or Previous Payments


JO.00
Net Amount This Payment
Ralance to Become Due (Inc. Retention)

S700.00
COM Properties Investmtni Ine 2720 W Chicago Ave Chicago, IL 60622

Touch N Oo Cleaning and Landscaping 1101 VV Cermak Chicago, IL 60621
THI Contractors Inc H905 Moore Or. Hrldgelvew, JL 6045,5

THI Contractors Inc 8*05 Moore Dr. Hrldgelvew, IL 604S5
Light Fixtures
?Extras
-Credits
Adjusted Contract Tutsi
Landscaping
+ExlnU -Credils
Adjusted Contract Total
Waste Fee ? Extras
-Credits
Adjusted Contract Tolal
miscellaneous
?Extras
•Credits
Adjusted Contract Total
51.500.00 50.00 SO.OO
JI.SOO.00
S3.5O0.uX ] SO.OO SO.OO
5*500.00
S2.50O.OO SO.OO $0.00
52,500.00
54,200.00 SO.OO SO.OO
54,200.00































Escrow No : draw No : 1 Pa9a : 3
Ami afCc-nincl $256,5011.00
Net af Previous Payments
so.oo
Balance to Become Due [inc. Retention) SO.OO $256,300.0.!)

AMOUNT OF ORIOINAL CONTRACT EXTRAS TO CONTRACT TOTAL CONTRACT AND EXTRAS CREDITS TO CONTRACT ADJUSTED TOTAL CONTRACT
$256,500.00 JO.OO
$256,500.00 , S0.00
$236,500.00
WORK COMPLETED TO DATE
TOTAL RETAINED
NET AMOUNT EARNED
NET PREVIOUSLY PAID
NET AMOUNT OF THIS PAYMENT
BALANCE TO BECOME DUE (Inn. Retention)
10.00 $0.00 $0.00 SO.OO JO.OO $256,500,00

It tj understood that lhe total amount paid to date plus the amount requited In thli application shall not exceed % ofthe coil af work completed to dute

1 agree to jUri»*h Waivers of Lien for all mu/erlah under my contract when demanded.

General Cbntrncmr

Subscribed and sworn (o before mc
The above room imement ihould he obtained by the owner before each and eMery payment.

Provided by Chicago- Till* and Trust
Official Ssai Evono E Anlea Notary Public Slate ol Illinois MyCommiMionExphes05rt9«02« ,

























Escrow No:

The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) ofthis 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 ofthis EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction: a violation of federal or state antitrust statutes; fraud: embezzlement; theft: forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any ofthe offenses set forth in subparagraph (b) above;
have not, during the 5 years before the date ofthis 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 ofthis EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5), (6) and (7) concern:

the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"):
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization ofa business entity following the ineligibility ofa 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 eniity;
any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 15

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date ofthis EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity ofa 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).

6. Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4: or (3) any similar offense of any state or ofthe United Stales of America that contains the same elements as the offense of bid-rigging or bid-rotating.

7 Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23,' Article I for applicability and defined terms] of the Applicant is currently indicted or charged with, or has admitted guilt of. or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the CityrN'OTE: 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.
[EOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit then-subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").
[FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not, without the prior written consent ofthe City, use any such
Vcr.20IX-l 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 ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:




If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

12.'To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 1 2-month period preceding the date ofthis EDS. an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").

ALIA

13. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Paity has given or caused to be given, at any time during the 12-month period preceding the execution date ofthis EDS. to an employee, or elected or appointed official, ofthe City of Chicago. For purposes ofthis 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 S25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N. A" or "none") As to any gift listed below, please also list the name of the City recipient.



C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ i is [v^ is not
a "financial institution" as defined in MCC Section 2-32-455(b).
Ifthe Disclosing Party TS 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 ofa predatory lender may result in the loss ofthe privilege of doing business with the City."

Pugc 7 or' 15

Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):




11" the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best oTthe 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?
! 1 Yes [v/no

NOTE. If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City ejected 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 docs not constitute a financial interest within the meaning ofthis Part D.

Does the Matter involve a City Property Sale?

| | Yes [ ] No
If you checked "Yes" to Item D( 1), provide the names and business addresses ofthe Cily officials or employees having such financial inierest and identify the nature ofthe financial interest"
¦r
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 ot'15

E CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either (1) or (2) below. Ifthe Disclosing Party checks (2), the Disclosing Party must disclose below or in an attachment to this EDS all information required by (2). Failure to comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step (I) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:





SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VI. Ifthe Matter is not federally funded, proceed to Section VII. For purposes ofthis Section VI, tax. credits allocated by the City and proceeds of debt obligations of the City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):




(If no explanation appears or begins on the lines above, or if the letters "NA" or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995, as amended, have made lobbying contacts on behalf ofthe Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(T) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Vcr.20lS-; Page 9 of 15

ofa 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 infonnation set forth in paragraphs A( 1) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request,

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.

Is the Disclosing Party the Applicant?
[ 1 Yes [ ] No

If "Yes." answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes [ ] No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ j Yes [ fNo L ] Reports not required
Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
I I Ves .[ | No

If you checked "No" to question (1) or (2) above, please provide an explanation:



Pa«c 10 ofls

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 ofthis 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, (3 12) 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 ofthe infonnation 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 infonnation 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. Ifthe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.








Page 11 of 15
CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications, and statements contained in this EDS, and all applicable Appendices, are true, accurate and complete as of the date furnished to the City.

(Print or type name of person signing)



(Print or type exactiegal name of Disclosing Party)


(Print or type title of person signing)


Signed and sworn to before me on (date) / O - J? 2.

at pock. County, //l^WoV-S (state).
Commission expires:


















Page 12 of 15
CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate and complete as of the date furnished to the City.


(Print or type exact legal name of Disclosing Party) By:
(Signh&e


(Print or type name of person
(Print or (ypi title of person signing)

Signed and sworn to before me on (date) atCcCV. CountyS^otC>
&f,
Notary Public Commission expires:







OFFICIAL SEAL
Wisam Kashour
NOTARY PUBLIC, STATE OF ILLINOIS
My Commission Expires Mar 25, 2023
"11|9
9|i ii „ ,i ¦ _


















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 ol" the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II. B. 1 a., ifthe Disclosing Party is a corporation; all partners ofthe Disclosing Party, ifthe Disclosing Party i.s a general partnership; all general partners and limited partners ofthe Disclosing Party, ifthe Disclosing Party i.s 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 ofthe Disclosing Party; and (3) any person having more than a 7.5% ownership interest m the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary ofa legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes

If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected;»(3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.









Page 13 of 15

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.
Pursuant to MCC Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
[ | Yes [vfiNo
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?

f ] Yes [ j No ["{The Applicant is not publicly traded on any exchange.
If yes lo (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!5

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.amleual.com ), generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in consideration for services, work or goods provided (including for legal or other professional services), or (ii) pay the 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, I hereby certify that the Applicant is in compliance with MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary history from current or former employers. 1 also certify that the Applicant has adopted a policy that includes those prohibitions.
[v{ Yes

[ JNo
[ ] N/A - I am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385. This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l). If you checked "no" to the above, please explain.




















Page 15 of 15

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION
Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
JouidA t^^fivw\.-k
Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:
[ ] the Applicant
OR
[l/f 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"), ajiirect or indirect interest in excess of 7.5% in the Applicani. State the Applicant's legal
name: Jo^vMa :Wf4OR
[ ] a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1)) State the legal name of the entity in which the Disclosing Party holds a right of control:
Business address of the Disclosing Party:

Telephone: fff? fo£ Fax: ZO ^SS-iVOf Email: ft '
Name of contact person: fA\-U , JfrtuA-i/i/^ ¦
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): C.,J7 UJ*fc-»v, U^D\0 S fJ*j*- Xl-, Pi5(t2 »J-rA.tf«. C^J^i^ v. ft*****'
w -S?Which City agency or department is requesting this EDS? f^^^^" ^ 1^^"^
Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #
Ver.2018-1 Page 1 of 15

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:
] Person 4£j Limited liability company
] Publicly registered business corporation [ ] Limited liability partnership
] Privately held business corporation [ ] Joint venture
] Sole proprietorship [ ] Not-for-profit corporation
] General partnership (Is the not-for-profit corporation also a 501(c)(3))?
] Limited partnership [ ] Yes [ ] No
] Trust [ ] Other (please specify)
2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
^IW^ .

3. For legal entities not organized in the State of Illinois: Has the organization registered to do
business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No [y[ 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 FiDS on its own behalf.

M^d^ ^DucUM Maa^/^ fkwkv-



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 coiporation, partnership interest in a partnership or joint venture, interest ofa member or manager in a

Page 2 of!5

limited liability company, or interest ofa beneficiary ofa 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 r- Business Address Percentage Interest in the Applicant
,yUy^l j&um>^ %c(o<> r*_tx,«_ £)f.




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 J/\]/No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City elected official during the 12-month perio d following the date of this EDS? [ ] Yes ^Jno
If "yes" to either ofthe above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:



Does any City elected official or. to the best ofthe Disclosing Party's knowledge after reasonable inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defined in Chapter 2-156 of the Municipal Code of Chicago ("MCC")) in the Disclosing Party? [ ]Yes f)()|No
If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic partner(s) and describe the financial interest(s).



SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and tlie 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 "t.b.d." is
^L* A rsn r\ ?la *i-f-ctc{- . not an acceptable response. ^


~T&£ /\> r^LJ&«> . - fcLdl \ ^ruJ^l!l Xl: ' (jfttm. ( ChUtfcr - ? ^ * ,(*~ ~(Add sheets if necessary) C^^Jt**^
[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V - CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.

Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes j)^)No 1" ] 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?

[ j Yes [ J No
FURTHER CERTIFICATIONS

[This paragraph 1 applies only ifthe Matter is a contract being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.


Page 4 of 15

SWORN STATEMENT FOR CONTRACTOR AND SUBCONTRACTOR TO OWNER AND TO CHICAGO TITLE AND TRUST
Commitment No.: Escrow No.: Draw No.: I
State of Illinois County of Cook
THE AFFIANT, being first duly swom, on oath deposes and says that he/she is of TBI Contractors Inc, 8905 Moore Dr, Bridgeview, IL, 60455 that has contract with MKB Business Strategies LLC And Joudeh Investment LLC & , owner for the following described premises in Cook County, lo wit: 3262 W Walnut St, Chicago, IL 60634/

That, for the purposes of said contract, the following persons have been contracted with, and have furnished, or are furnishing and preparing materials for, and have done or are doing labor on said improvement That there is due them, respectively, the amounts set opposite their names for materials or labor as stated. That this statement is a full, true and complete statement of all such persons, the amounts paid and the amounts due or to become due to each,
(Inc Current) Paymrnli This Payment
tj . . j j ^. . ,,., , . , _ , Hctenllon N el of Previous N ei Amount ,. ^M'llnce 10
n orae and Address Kind of Work Ami of Contract ,. „ „ a , T D , Ueeonie Due
(Ine. Retention)
Msrla V Contracting, Inc. Excavating SI3.300 00
7818 N . 7irJCl + Exlras 1000
Elmwood. IL 60707 -Credit! JO.OO
Adjuileil Contract Total 3iJ.50O.Q0 SO.OO 10 03 $0.00 113.300.00
Mlria V Contracting, Inc. foundation 130,000,00
28I8N . 71rdCI. +E«lra! 10.00
Elmwood, IL 6 0 707 -Credits SO.OO
Adjusted Canlrirl Total 130,000.00 S O 00 JO.OO SO.OO 130,000.00
?OM Coil [ruction Inc Carpentry 140.300.00
2720 W Chicago Ave +Extns 10.00
Chicago, il 60622 -Credils JO.OO
Adjusted Contract Total 40,300.00 50,00 SO.OO SO.CO 140JCO.OO
United Builders Oroup CO Masonry $13,000 00
2700 Patriot Bivd 4-Exlras SO.OO
Glenview. It. 60026 -Credits 10.00
Adjusted Contract Total 113.000.00 SO.OO JO.OO 10 00 S I3.00O.GO
Pawcl's Plumbing sewer/water $15,000.00
3228 NPIiinfidd Ave +Exlnls SO.OO
Chicsgo, IL 60634 -Credit* JO.OO
Adjusted Contract Total 111,000.00 JO.OO 10.09 10.00
Pawcl's Plumbing Plumbing 120,000 00
322BN PlainfieldAve +Exlras 10.00
Chicago, IL 60634 -Credits SO.OO
Adjuited Conlract Tolal 120,000.00 10.00 SO.OO SO.OO 120,000,00
Mechanical Brothers HVAC J9.200.00
22W 418Hillcrcas(Tcn. +Extr« 10.00
Medloah, 1L 60157 -Credits SO OO
Adjusted ContractTotal 19.100.00 $ 0,00 50.00 10.00 19,200.00
Bolek Electric Electrical $15,000,00
673 Brentwood Ave tExIras 10.00
Elk Grove Village, IL 60007 -Credits SO.OO
Adjuited Conlract Tolal 115,000.00 10.00 10.00 10 00 115,000.00






Escrow No ; Draw No : 1
Name and Address
Climate Guard


Ljch Conslruclion UORNnue Rd Paliline, IL 60061
Kind of Work
windows +F.xlras -Credits
Adjusted Contract Total
Roof, siding, front panels
+Extras
-Credits
Adjusted Contract Tolal
Amt of Contract
S6.50COO SO 00 SO.OO
S6.500.00
12.1,800 0C JO.OO SO.OO
HMOo.oo
Retention (Inc. Current)


SO.OO
Nel of Previous Net Amount H«l«nce to
Payments This Payment ,. H'"mt, >u'
' (Inc. Helrnllnn)

JO.OO SC.00 S6.SO0.O0


JO.OO JO.OO J23,*OD.OO
SafeT
3140 2Slh Avo Shlllcr Park. IL 60126

C.HD.C. Construction, LLC 2105 W Walton Street, Chicago, IL 60622

C.R.D.C. Conslruclion, LLC 2I0S W Walton Street, Chicago, IL 60622
low voltage
4-Eitras
-Credits
Adjuited Cnnlrael Tolal
Orywall + Extras -Credils
Adjusted Contract Total
Insulation +Exlras Credits
Adjusted Contract Total
S2,PO0.OC SO 00 JO.OO
si.aoooo
$1,500.00
so.oo
JO.OO S1.500.00
S3.000.00 SO 00
so.oo J3.ooo.ao
C R.D C. Conslruclion, LLC 2)05 W Walton Slrccl. Chicago, IL 60622
painting + Extras -Credits
Adjusted ContractTotal
$4,000,00 SO.OO SO.OO
14,000.00
DOM Properties Inveslmeni Inc 2720 W Chicago Ave Chicago, IL 60512

C R.D.C, Conslruclion. LLC 2IGS VV Wollon Slrccl, Chicago, IL 60622

C R.D C. Conltru:(loo, LLC 2105 \v Wallon Street, Chicago, IL 60622

JO whiripooleVbalri outlet inc 2730 North Elslon Ave Chicago, IL 40647
fence *¦ Extras ¦Credits
Adjusted Conlract Tolal
Floor Covering
¦t-Exlrai;
-Credits
Adjusted Contract Total
mil I work A hardware "-Extras Credils
Ad|usled Contract Toul
plumbing nxlurcs ¦t-Exirss Credils
Adjusted Contract Total
S6.500 OO SO 00 SO.OO
16,500.00
S 5,000.00 SO 00 SO 00
15,000.00
$5,000 00 SO 00
so.oo
56,000,00
53,500.00 JO.OO SO.OO
S3.50O.0O
DOM Properties Investment Inc 2120 W Chicago Ave Chicago, IL 60622
Interior stairs + Exlras -Credits
Adjusted Cunlracl Tulil
{2,500.00 SO.OO $0.00
51,500.00
DOM Properties Investment Inc 2720 W Chicago Ave Chicago, IL60622
Exterior stairs
¦t-ExIras
-Credlb
Adjusted Cnntract Tola!
$4,000.00 $0.00 SO 00
S4.000.00
DOM Properties Inveslmeni Inc 2720 W Chicago Ave Chicago. IL 60621
counlerlOfiS
+E*tral
-Credos
Adjusted Co.olracl Total
$2,000 00 $0 00 10.00
52,000,30
?OM Properties Inveslmeni Inc 2720 W Chicago Ave Chicago, IL60622
Appliances
+Extras
-Credits
Adjusted Conlract Total
S3,000 00 SO.OO SO.OO
S3.000.tIO
Klnxlni LLC 2720 W Chicago Chicago, IL 60622

DOM Prapertle« Inveslmeni Inc 3730 W Chicago Ave Chicago, IL 60622
cabincla ^-Extras -Credita
Adjusted Contract Tolal
tlle> + Ralr«i
•Credits
Adjusted Contract Total
$3,000 00 SO.OO SO.OO
$3,000.00
S5.000.00 SOOO $0.00
S5,oao.oo

Escrow No . Oraw No : 1 PaBB : 2
Name and Address
GP Company glass
III] Belly dr
Lake Zurich, IL 60047
Kind oT Word
shower, mirrors +Exl;es Credils
Adjusted Cnnlrxct Tolal
Ami of Contract
sioaoo
SO 00 SO.OO I7D0.0Q
Hetenllcn Net Df Previous Net Amount
(Inc Current) Payments This Payment


$0.00
Balance to Recome Hue (Inc. Kelentlon)

$700.00
DOM Properties Inveslmeni Inc 2720 W Chicane, Ave ChlcagD, 11.60622

Touch N Go Craning and Landicaplng MO I w Cermak Chicago, IL6062I
THI Contractors he 8905 Moore Dr. Hrldgelvew, JL

THI Conlrictors Inc 8905 Moore Or Hrldgelvew, IL 60455
Ligbl Fixtures + Exlros -Credils
Adjusted Conlract Total
Landscaping +Extrti
¦Credits
Adjusted Conlract Tsui
Waste Fee ? Extras ¦Credils
Adjusted Conlract Tolal
miscellaneous + Exlr»s -Credits
Adjusted Conlract Total
SI.50O.00
so.oo so.oo
51,500.00
57,500 00
so.oo so oo suoo.oo
S2,500.OO Sfl.00
so.oo
$2,500.00 S4.200.00
so.oo
SO.OO $4,100.00
































Draw No: 1
Ami of Con«racl 5256,500.00
Ncl orPrevioul Payments
SO.OO
Balance to
Become Ouc
(inc. Retention)
SO 00 5 256,500.00

AMOUNT OF ORIGINAL CONTRACT EXTRAS TO CONTRACT TOTAL CONTRACT AM.) EXTRAS CREDITS TO CONTRACT ADJUSTED TOTAL CONTRACT
S25h.500 00 SO.OO
5256,500 00 SO.OO
5256.500.00
WORK COMPLETED TO DATE
TOTAL RETAINED
NET AMOUNT EARNED
NET PREVIOUSLY PAID
NET AMOUNT OF THIS PAYMENT
BALANCE TO BECOME DUE (Inc. Retention)
JO.OO SO 00 SO.OO SO 00
sooo
S256,SO0.00


It is wideritoPd (hat Ihe total amount paid to data plus the amount requested In this application shall not exceed % ofthe cost of nark completed to dote
General (SintraalDr

1 a^ree to Jurl'ish Waivers of Lien for all materials under my contract when demanded. | J ftjjji/

Subscribed and swom

lo before inc. this day of.
The above sworn statement should be obtained by the owner before each and every payment

Provided by Chicago Tille and Trust
Official Seal Evono £ Antos Nolaty Pub"= Slile of. Illinois MV Commission Expire* 06/29/2024

























Escrow No :

The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) ofthis EDS:

arc 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

c. 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).

5. Certifications (5), (6) and (7) concern:
o the Disclosing Party;
o any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, mcluding but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); » any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is. with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization ofa 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;
o any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 15




Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor, nor any Agents have, during the 5 years before the date ofthis EDS, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity ofa Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:
bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency 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 2-9'2-320(a)(4)(Contracts Requiring a Base Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or ofthe United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.
Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the United States Department of Commerce, State, or Treasury, or any successor federal agency.
[FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter ! -23, Article I for applicability and defined terms] ofthe Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgeiy, perjury, dishonesty or deceit against an officer or employee ofthe City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.
[FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").

10. [FOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired
or to be hired in connection with the Matter certifications equal in form and substance to those in
Certifications (2) and (9) above and will not, without the prior written consent ofthe City, use any such
Ver.2018-1 Page 6 of 15
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to believe has not provided or cannot provide truthful certifications.

11. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:




Ifthe letters "NA," the word "None," or no response appears on the lines above, it will, be conclusively presumed that the Disclosing Party certified to the above statements.

12. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the date of this. EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").

13. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, ofthe City of Chicago. For purposes ofthis 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 tlie City recipient.



C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is ffi] is not
a "financial institution" as defined in MCC Section 2-32-455(b).
Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges :
"We are not and will not become a predatory lender as defmed 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 ofa predatory lender may result in the loss of the privilege of doing business with the City."

Page 7 of 15

Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):




Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING FINANCIAL INTEREST TN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.
In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge after reasonable inquiry, does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
[ ] Yes L^No

NOTE. If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D(l), skip Items D(2) and D(3) and proceed to Part E.
Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any-other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

f 1 Yes [ ] No
If you checked "Yes" to Item D(l), provide the names and business addresses ofthe City officials or employees having such financial interest and identify the nature ofthe financial interest:

Name Business Address Nature of Financial Interest





4. The. Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

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 infonnation 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. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:





SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not federally funded, proceed to Section VU. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations ofthe City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):




(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

ofa member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement. or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A(l) and A(2) above.
The Disclosing Party certifies that either: (i) 'it is not an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined'in the Lobbying Disclosure Act of 1995, as amended.
Ifthe Disclosmg Patty is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.

Is the Disclosing Party the Applicant?
[ ]Yes [ ]No

If "Yes," answer the three questions below:
Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)
[ ]Yes [ ]No
Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
[ ] Yes [ ] No [ ] Reports not required
Have you participated in any previous contracts or subcontracts subject to the . equal opportunity clause?
[ j Yes [ ] No

If you checked "No" to question (i) or (2) above, please provide an explanation:



Page 10 of 15

SECTION VII -- FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:
The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Paity 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 vvww.cityofchicago.org/Ethics , and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610, (3'. 2) 744-9660. The Disclosing Party must comply fully with this ordinance.
Ifthe City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all ofthe infonnation 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 information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1-23 and Section 2-154-020.








Page 11 of 15
CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS. and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate and complete as of the date furnished to the City.



(Print or j^ge-ysxact leg#J? napff of Disclosing Party)

^type'name of person
signing)
(Print oretype
ivw^.vvx (WW-
(Print or type title of person signing)


Signed and sworn to before me on JljfttyM^ ^/ ^P-^ .
at i^^/k- County, t^/Z^y (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., ifthe Disclosing Party is a corporation; all partners ofthe Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, ifthe Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, ifthe Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5% ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary ofa 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?


Tf yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.









Page 13 of 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 scoffiaw or problem landlord pursuant to MCC Section 2-92-416?


2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?

[ jYes


3. If yes lo (1) or (2) above, please identify below the name of each person or legal entity identified as a building code scofflaw or problem landlord and the address of each building or buildings to which the pertinent code violations apply.
























Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as defined in MCC Section 2-92-385. That section, which should be consulted (www.amlegal.com' ), generally covers a paity 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. 1 also certify that the Applicant has adopted a policy that includes those prohibitions.


[ ]No

[ j N/A - I am not an Applicant that is a "contractor" as defmed in MCC Section 2-92-385.

This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(l).

you checked "no" to the above, please explain.




















Page 15 of 15

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A. Legal name ofthe Disclosmg Party submitting this FDS. Include dba. if applicable:
N £ fc> >ju. ->/,u^ S h-a-t ^, t
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this FDS is:
[ ] the Applicant
[y] a legal entity currently holding, or anticipated lo hold within six months after City action on
the conlract, 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: „k' r\j.[\ i Oh ?ybi'£ ;i.R (JvC / M K-fr O±^ L/L"c'i'S ^.f^fta i* £ lA±Ar_
OR '
j ] 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:

Business address ofthe Disclosing Party: lfj ^1 LU ¦ M ft i ¦ S.' -\.
tLTelephone: %0^-yj5 "7;,±lij Fax: 1'). "ri h ') s',6-/ Email: ; .,.„
Name of contact person. Mdv - ,\ 7^>'>¦•/?/
H. Federal Employer Identification No. (if you have one): _
F. Brief description ofthe Matter to which this EDS pertains. (Include project number and location of
property., if applicable): d,4 fw. i.,0.:V:.l6^ h^wliss 'lL.^^ T^.aK. 71 "



G Which City agency or department is requesting this EDS0 o rlmc^t :' / ri \i&SIfthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:
Specification ¦¦ Ver 20 i 8-i

SECTION'.! - DISCLOSURE OF OWNERSHIP INTERESTS

A NA TURE OF THE DISCLOSING PARTY
[ J Person
[ j Publicly registered business corporation
| ] Privately held business corporation
| j Sole proprietorship
[ | General partnership
[ J Limited partnership
[ I Trust
[J\ Limited liability company [ J Limited liability partnership [ J Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))'?
• [ ] Yes [ ] No
[. ] Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
/ LL/ddiS
3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

| | Yes [ ) No [/] Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1 List below the full names and titles, if applicable, of: (i) all executive officers and all directors of the entity, (ii) for not-for-profit corporations, all members, if any, which are legal entities (if there arc no such members, write "no members which are legal entities"); (iii) for trusts, estates or other similar entities, the trustee, executor, administrator, or similarly situated party; (iv) for general or limited partnerships, limited liability companies, limited liability partnerships or joint ventures, each general partner, managing member, manager or any other person or legal entity that directly or indirectly controls the day-to-day management ofthe Applicant.

NOTE- Each legal entity listed below must submit an EDS on its own behalf.

Name ^ Title





2. Please provide the following information concerning each person or legal entity having a direct or indirect, current or prospective (i.e. within 6 months after City action) beneficial interest (including ownership) in excess of 7.5% ofthe Applicant. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture, interest ofa member or manager in a

Page 2 of" 15

limited liability company, or interest ofa beneficiary ofa trust, estate or other similar entity [f 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

: CVix-r.-ac TL U>Dlo^ L... ::



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 EDS9 I JYes [.V^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 FDS? [ ] Yes [ \/\ No

If "yes" to either ofthe above, please identify below the name(s) of such City elected official(s) and describe such income or compensation:



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 Code of Chicago ("MCC")) in the Disclosing Party?
[ ] Yes [V\ No " ' ~

If "yes," please identify below the name(s) of such City elected ofTicial(s) and/or spouse(s),'domestic partner(s) and describe the financial lnterest(s). ~"



SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing'Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll. Ifthe Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 ol' 15

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
^ HzcI f3la.tnfit.(/J notanacceptablerespon.se . N

icA^Son +L££. Lj-d-Rt_hnir\iJ - cV.cg^- ,H " A-ro kff*-t-f~--Plfligf 53-j700O (iujaj, U^Wtly/j
(Add sheets if necessary >^C;,-4r^r Sfc^H Gri| j Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities. SECTION V -- CERTIFICATIONS
COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under MCC Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.

Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ 1 Yes No [ ] No person directly or indirectly owns 10% or more ofthe Disclosing Party.

If "Yes." has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[ 1 Yes [ ] No
FURTHER CERTIFICATIONS

[This paragraph 1 applies only ifthe Matter is a contract, being handled by the City's Department of Procurement Services.] In the 5-year period preceding the date ofthis EDS, neither the Disclosing Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the performance of any public contract, the services of an integrity monitor, independent private sector inspector general, or integrity compliance consultant (i e., an individual or entity with legal, auditing, investigative, or other similar skills, designated by a public agency to help the agency monitor the activity of specified agency vendors as well as help the vendors reform their business practices so they can be considered for agency contracts in the future, or continue with a contract in progress).
The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee, tax or other source of Indebtedness owed to the City of Chicago, including, but not limited to, water and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.


Page 4 of 15
SWORN STATEMENT FOR CONTRACTOR AND SUBCONTRACTOR TO OWNER AND TO CHICAGO TITLE AND TRUST
Commitment No.: Escrow No.: Draw No.: I
State of Illinois County of Cook
THE AFFIANT, being first duly swom, on oath deposes and says that he/she is of TBI Contractors Inc, 8*305 Moore Dr, Bridgeview, IL, 60455 that has contract with MKB Business Strategies LLC And Joudeh Investment LLC & , owner for the following described premises in Cook County, tu wit: 3262 W Walnut St, Chicago, IL. 60614/

That, for the purposes of said contract, the following persons have been contracted with, and have furnished, or are furnishing and preparing materials for, and have done or are doing labor on said improvement. That there is due them, respectively, the amounts set opposite their names for materials or labor as stated. That this statement is a full, true and complete statement of all such persons, the amounts paid and the amounts due or to become due to each,
N nine una Address
Maria V Contracting. Inc. 2818 N . 73rd C!. Elmwood. IL 60707
Kind of Work
Excavating
?Extras
-Credit
Adjuited Contract Totnl
Amt of Contract
SI3.50O.0O JO 00 JO.OO
5:3.500.00
Hulunee to Mfcame Due (inc. Retention)

S13.500.Ofl
Maria V Contracting, Inc. 28IH N . 73rd Cl. Elmwood. IL 60707
foundation ? Extras ¦Credits
Adjusted Contract Total
530,000.00 SO.OO SO.OO
S30.onu.no
?OM Coil Iructicn tnc 2720 W Chicago Ave Chicago, il 60622

United Builders Group CO 2700 Patriot Illvd Glenview. IL. 60026
Carpentry
?Extras
-Credits
Adjusted Contract Total
Masonry ? Extras -Credits
Adjusted Contract Tutal
S-M.3U0.00 SC.00
so.oo
•10,300.00 SI 3.000.00
so.oo so.oo
513.000.00
Pawcl's Plumbing 3228 NPIainficId Ave Chicago, IL 60634
sewer/water
?Extras
¦Credit*
Adjuited Conlract Tutal
515,000.00
so.oo so.oo
SI 5,000.00
Pawcl's Plumbing 3228N PlamfieluAve Chicago.IL 60634

Mechanical Brothers 22 W 4l8HillcrcastTm Medinah, 11. 60IS7
Plumbing
?¦Extras
¦Credils
Adjusted Contract Total
HVAC ?Extras ¦Credits t,
Adjusted Contract Total
520,000.00 50.00 50.00
S20,ooo.oa
59.200.00 SO.OO SO.OO
59.200.00
Bolek Electric
673 Brantwood Ave
Elk Grove Village, IL S0007
Electrical ? Exlras ¦Credils
Adjuited Contract Total
SI 5.000.00 SO.OO 5(1.00
515.000.00






Escrow No ¦ Draw No : 1 Psa« : 1
Name and Address
Climate fiuard


Lucas Construction 1208 N Doe Rd Palatine, IL 60067

SafeT
3740 25th Ave Shillcr Park. IL 60176

C.R.D.C. Construction, LLC 2105 W Walton Street, Chicago, IL 60622

CR.D.C. Construction, LLC 2105 W Walton Street, Chicago. IL 60622
Kind nf WnrW
windows ? Extras -Credits
Adjusted Cnntract Total
Roof, siding, front panels
?Extras
-Credits
Adjusted Contract Total
low voltage
?Extras
¦Credits
Adjusted Conlract Tntal
Drywall ?Extras -Credils
Adjusted ContractTotal
Insulation
?Extras
-Credits
Adjusted ContractTotal
Amt of Contract
56,500,00 50 00 50.00
56,500.00
S23.SO0.OO 50.00
so.oo
513,800.00
52,800.00 SO.OO JO.OO
S2.Aoo.no
57,500.00 50.00
so.cn
57,500.00
13.000.00 SO 00 50.00
53.000.00
Retention (Inc. Current)


JO.OO


so.oo

Become Due (Inc. Retention)
Net uf Previous Net Amount Payments This Payment

JO.OO SO.OO V6.500.00


SO.OO 50.011 523,000.00


50.00 50.00 52.HOO.0O


so.on so.no si.soo.oo


50.00 50.00 53,000.00
C.R.H.C. Construction, LLC 2105 W Walton Street, Chicago, IL 60622
painting ? Extras -Credits
Adjusted Cnntract Total
54,000.00 SO.OO 50.00
54.000.00
DOM Properties Investment Inc 2720 W Chicago Ave Chicago, IL 60622

C.HD.C. Construction, LLC 2105 \V Wallon Jt.-ccl. Chicago, IL 60622

CR.D.C Construction, LLC 2105 W Walton Slrccl, Chicago, IL 60622
fence
•-Extras
•Ctcdits
Adjusted Contract Total
Kloor Covering
?Extra*
-Credils
Adjusted Cnntract Total
rnillwork&hardware
?Extras
-Credits
Adjusted Cnntract Total
56,500.00 JO.OO SO.OO
56,500.00
55.OOO.0C JO.OO SO.OO
55,000.00
56,000.00 SO.OO 50 00
56,000.00
JD whirlpoolAtbath outlet inc 2130 North Elston Ave Chicago, IL 60647
plumbing fixtures ? Extras -Crodiis
Adjusted Contract Total
53,500.00 50.00 SO.OO
SJ ,500.00
DOM Properties Investment Inc 2720 W Chicago Ave Chicago, IL 6(1622

OOM Properties investment Inc 2720 W Chkagu Ave Chicago, IL 60622
Interiur stairs
-Extras
-Credils
Adjusted Cuntrict tolal
Exterioi stairs
-r-F.xlras
-Credit!
Adjusted Cnntract Tntal
52.500.00 50.00 SO 00
52,500.00
J4.fl00.00
so.oo so.oo
54,000.00
DOM Properties Investment Inc 2720 W Chicago Ave Chicago. IL 60622
countertops ? Extras -Credits
Adjusted Cnntract Total
52,000.00 50 00 50.00
52,000.00
DOM Properties Investment Inc 5120 VV Chicago Ave Chicago, IL60622
Appliances
?F.xtns
-Credits
Adjusted Contract Tolal
S3.000 00 SO.OO 50.00
j3,oon.oo
Kinzini LLC 2720 W Chicago Chicago. IL 60622
cabinets ? Extras ¦Credils
Adjusted Contract Total
13,000.00 10.00 50.00
53,000.00
DOM Properties Investment Inc 2720 W Chicago Ave Chicago, IL 60622
tilet
?Extras
-Credils
Adjusted Contract Total
$5,000 00 SO.OO SO.OO
55,000.00

Escrow No . Orow No : 1 PaBa : 2
Name and Address
GP Company glass
11 a: Betty dr
Lake Zurich, IL 600(7
Kind of Work
shower, mirrors ? Extras -Credils
Adjusted Contract Total
Amt ofContract
5700.00 SO.OO
so.oo
$700.00
Ketentlnn (Inc. Current)


SO.OO
Net or Previous Payments


JO.OO
Net Amount This Payment


JO.OO
Halance to Became Due (Inc. Retention)
DOM Properties investment inc 2720 W Chicago Ave Chicago, II. 60622

Touch N Go Oeanlng and
Landscaping
1101 W Cermak
Chicago, IL 6062!
Light Fixtures
Extras -Credits
Adjusted Contract Total
Landscaping
Extras -Credits
Adjusted Contract Total
$1,500.00 SO 00 JO.OO
$1,500.00
S3.500.00 SO.OO JO.OO
$3,500.00
TH; Contractors Inc t'JOi Moore Dr. Hrldgelvew, IL60455
Waste Kee ? Extras -Credits
Adjusted Contract Tolal
J2.500.00 JO.OO $0.00
52,500.00
THI Contractors Inc a*)5 Moore Dr. Hrldgelvew, IL 60455
miscellaneous ? Extras •Credits
Adjusted Contract Tolal
54.200.00 SO.OO 50 00
54,200.00


































Escrow No :
Ami af Conlract
S256,5on.no
Net of Previous Payments
so.oo
Net Amount This Payment
(O.OQ
Balance to Become Due (inc. Retention) J256.500.00

AMOUNT OF ORIGINAL CONTRACT EXTRAS TO CONTRACT TOTAL CONTRACT AND EXTRAS CREDITS TO CONTRACT ADJUSTED TOTAL CONTRACT
S25fi.500.00 JO.OO
1256,5 00.00 JO.OO
1256,300.00
WORK COMPLETED TO DATE
TOTAL RETAINED
NET AMOUNT EARNED
NET PREVIOUSLY PAID
NET AMOUNT OF THIS PAYMENT
BALANCE TO BECOME DUE (Inc. Retention)
so on jo oo so.oo
10.00
so.oo
5256,500.00

ll is understood lhal Ihe total amount paid to date plus the amount requested In this application shall not exceed % of the cost af fork completed to date.

I agree to furnish Waivers of Lien for all materials under my contract *>hen demanded

den era I "(Hinirnclnr

Subscribed and swam to before me
The above sworn statement should be obtained hy the owner before each and every payment.

Provided by Ch/cayn Tllle and Trust
Official Seal Evonn E Antos Notary Public Sula ol »»«°» MyCammtMion Expires OS/29/2024


























Draw No-.1 Pa9e'4

The Disclosing Party and, ifthe Disclosing Party is a legal entity, all of those persons or entities identified in Section 11(B)(1) ofthis 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 ofthis EDS, been convicted ofa criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud: embezzlement; theft: forgery: bribery: falsification or destruction of records; making false statements; or receiving stolen property;
are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any ofthe offenses set forth in subparagraph (b) above:
have not, during the 5 years before the date ofthis 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 ofthis EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.
The Disclosing Party understands and shall comply with the applicable requirements of MCC Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).
Certifications (5). (6) and (7) concern:

the Disclosing Party:
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in •connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV. "Disclosure of Subcontractors and Other Retained Parties"),
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is. with the Disclosing Party, under common control of another person or entity). Indicia of control include, without limitation, interlocking management or ownership: identity of interests among family members, shared facilities and equipment: common use of employees: or organization ofa business entity following the ineligibility ofa business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity. With respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity,
any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Eniity, acting pursuant to the direction or authorization ofa responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 15

I

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 ofthis EDS. or, with respect to a Contractor, an .Affiliated Entity, or an Affiliated Entity ofa Contractor during the 5 years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a 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 officers 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 Stales 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. Slate, or Treasury, or any successor federal agency.
[EOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC Chapter 1-23. Article I for applicability and defined terms] ofthe Applicant is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of. or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any "sister agency"; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement fordoing 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.

9 | FOR APPLICANT ONLY] The Applicant and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed as having an active exclusion by the U.S. EPA on the federal System for Award Management ("SAM").

10. [EOR APPLICANT ONLY] The Applicant will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in Certifications (2) and (9) above and will not. without the prior written consent ofthe City, use any such
V'lt.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.

1 1. Ifthe Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further Certifications), the Disclosing Party must explain below:




If the letters "NA." the word "None." or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

12. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 1 2-inonth period preceding the date ofthis EDS, an employee, or elected or appointed official, ofthe City of Chicago ( if none, indicate with "N/A" or "none")

. M./A I .

13. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Partv has given or caused to be given, at any time during the 12-month period preceding the execution date ofthis EDS. to an employee, or elected or appointed official, ofthe City of Chicago. For purposes ofthis statement, a "giff does not include: (i) anything made generally available to City employees or to the general public, or ( ii) food or drink provided in the course of official City business and having a retail value of less than $25 per recipient, or (iii) a political contribution otherwise duly reported as required by law (if none, indicate with "N A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
z"jj/a\.~ . .__ .. .7 .

C. CERTIFICATION OF STATUS AS FINANCIAL. INSTITUTION
The Disclosing Party certifies that the Disclosing Party (check one)
I. I is [i/i is not

a "financial institution" as defined in MCC Section 2-32-455(b)
Ifthe Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We 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 w ill 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 ol" doing business with the City."

Pauc 7 or" 15

Ifthe Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain here (attach additional pages if necessary):




Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-1 56 have the same meanings if used in this Part D.

1. In accordance with VICC Section 2-156-1 10: To the best ofthe Disclosing Party's knowledge alter reasonable inquiry, does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?
/


NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No" to Item D( 1), skip Items D(2) and D(3) and proceed to Part E.

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively. "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning ofthis Part D

Does ihe Matter involve a City Property Sale'7

L I No
3. If you checked "Yes" to Item D( 1), provide the names and business addresses ofthe City official, or employees having such financial interest and identify the nature ofthe financial interest:

Nature of Financial Interest






4 The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either (1) or (2) below. 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. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:






SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VT. Ifthe Matter is not federally funded, proceed to Section VII. For purposes ofthis Section VI. tax credits allocated by the City and proceeds of debt obligations ofthe City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995. as amended, who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):




(If no explanation appears or begins on the lines above, or ifthe letters "NA" or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995, as amended, have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pi
any person or entity listed in paragraph A( 1) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as definec
by applicable federal law . a member of Congress, an officer or employee of Congress, or an employ',
Ver201S-1 Page 9 of 15

of a.member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A( 1) and A(2) above.
The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities," as that term is defined in the Lobbying Disclosure Act of 1995. as amended.
Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A(l) through A(4) above from all subcontractors before it awards any subcontract and the Disclosing Party mustjnaintain 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

Ifthe Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations

Is the Disclosing Party the Applicant?
[ | Yes [ 1 No

If "Yes,'' answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations0 (Sec 41 CFR Part 60-2.)
[ 1 Yes [ ] No
|109|" I lave you filed with the Joint Reporting Committee, the Director of the Office of Federal Conlract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?
| | Yes f f No [ ] Reports not required
|109|Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?
| ] Yes I I No

If you checked "No" to question (1) or (2) above, please provide an explanation:




Page 10 of 15

SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:
The certifications,,disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to.the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.
The City's Governmental Ethics Ordinance, MCC Chapter 2-156. imposes certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text ofthis ordinance and a training program is available on line at w w w. c 11 y o fc h i c a g o. o r g/ Et h i c s, and may also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago. IL 60610. (3 12) 744-9660. The Disclosing Party must comply fully with this ordinance.
Ifthe City determines that any information provided in this EDS i.s false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other City transactions. Remedies at law- for a false statement of material fact may include incarceration and an award to the City of treble damages.
It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all ofthe information provided in, and appended to, this EDS may be made publicly available on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible right* or claims which it may have against the City in connection with the public release of informalion contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.
The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. Ifthe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter 1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by MCC Chapter 1 -23 and Section 2-\ 54-020.








Page 11 of 15

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this FDS, and ail applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained m this EDS. and all applicable Appendices, are true, accurate and complete as of the date furnished to the City.



(Print or type exact leaal name of Disclosing Party)

By: ^ :.X V\
(Sign licre-J

?-JxU;r( Print or type name of person signing)

N^A&,,Vrt ^JfW&r'?-
(Print or type title of person signing)


Signed and sworn to before mc on (date) / 0 ~ /' 1"ll'.-l.

"t C.COK County. / LL/nlo,i, (state).
, ,-¦ f /
_ _ . /'¦<¦ / 7. /^.c >
OFFICIAL SEAL ALANCA TURNER
NOTARY PUBLIC - STATE OF ILLINOIS MY COMMISSION EXPIRES.03/26/M
Notary Public ; "v Commission expires: V^c- /* ''¦




['age 12 of 15

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMEN I 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 ll.B.l.a ifthe Disclosing Party is a corporation; all partners ofthe Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Parly, il the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, ifthe Disclosing Party is a limited liability company: (2) all principal officers ofthe Disclosing Party; and (3) any person hav ing more than a 7.5% ownership interest m the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary ofa 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?

[ .1 Yes

If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected;#(3) the name and title 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 SCOFI LAW/PROBLEM LANDLORD CERTIFICATION

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5% (an "Owner"). It is not to be completed by any-legal entity which has only an indirect ownership interest in the Applicant. i
Pursuant to VICC Section 2-1 54-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?
| | Yes [vf No
Ifthe Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section 2-92-416?

| j Yes [ ] No [K^The Applicant is not publicly traded on any exchange.
If yes lo (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 lhe address of each building or buildings to which the pertinent code violations apply

























Page 14 of 15
CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor"" as defined in MCC Section 2-92-385 That section, which should be consulted (www.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)(I) and (2), which prohibit: ti) screening job applicants based on their wage or salary history, or (ii) seeking job applicants' w;age or salary-history from current or former employers. I also certify that the Applicant has adopted a policy that includes those prohibitions.



I 1 No

[ ] N/A - 1 am not an Applicant that is a "contractor'" as defmed 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'1 to the above, please explain.





















Pa«c 15 oi' 15